B-RELYT Membership Registration Form and Registration 2025

The B-RELYT Organization, Inc dba B-RELYT Math Collective
B-RELYT Membership Registration and Registration 2025–2026 Programs

Mission: To empower, uplift, and expand opportunities through Math for all communities.
Overview

To support long-term sustainability and ensure we can continue delivering high-quality programs, BMC is transitioning to a membership model. While we actively pursue grantfunding, we recognize that we cannot rely solely on external funders. That’s why your support is so important. As a registered 501(c)(3) nonprofit, your membership fee is tax-deductible. Membership is per household and covers all students residing at the same address.
Parent/Guardian Information
Parent/Guardian 1 Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email - Parent/Guardian 1*
example@example.com
Cell Phone - Parent/Guardian 1*
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian 2 Full Name

First NameLast Name
Email - Parent/Guardian 2
Cell Phone - Parent/Guardian 2
Does the student live at Parent/Guardian 1’s address? If no enter Parent/Guardian 2’s address below. Otherwise write N/A*
Emergency Contact Information
Emergency Contact Full Name*

First NameLast Name
Cell Phone- Emergency Contact*
Please enter a valid phone number.Format: (000) 000-0000.
FamilyGuardianRelativeFriendOther
Student Information
1234
Student 1 Full Name *

First NameLast Name
Grade of Student 1 (2025–2026)*
Date of Birth Student 1*

MonthDayYear
School of Student 1*
Elementary School MathMiddle School MathAlgebra 1GeometryAlgebra Pre-Calc/TrigCalculus 1Other
Summer Math Intensive – Hybrid (Grades 6–12)Saturday School (2nd–8th grade)Math Revolutions @ UCLA (2nd–8th grade)1-on-1 Tutoring (Premium Members or hourly rate $50/hour -members $100/hour non- members
Student 2 Full Name *

First NameLast Name
Grade of Student 2 (2025–2026)*
Date of Birth Student 2*

MonthDayYear
School of Student 2*
Elementary School MathMiddle School MathAlgebra 1GeometryAlgebra Pre-Calc/TrigCalculus 1Other
Summer Math Intensive – Hybrid (Grades 6–12)Saturday School (2nd–8th grade)Math Revolutions @ UCLA (2nd–8th grade)1-on-1 Tutoring (Premium Members (1 math topic and 3 consecutive session) or hourly rate $50/hour -members $100/hour non-members
Student 3 Full Name *

First NameLast Name
Grade of Student 3 (2025–2026)*
Date of Birth Student 3*

MonthDayYear
School of Student 3*
Elementary School MathMiddle School MathAlgebra 1GeometryAlgebra Pre-Calc/TrigCalculus 1Other
Summer Math Intensive – Hybrid (Grades 6–12)Saturday School (2nd–8th grade)Math Revolutions @ UCLA (2nd–8th grade)1-on-1 Tutoring (Premium Members or hourly rate $50/hour -members $100/hour non- members
Student 4 Full Name *

First NameLast Name
Grade of Student 4 (2025–2026)*
Date of Birth Student 4*

MonthDayYear
School of Student 4*
Elementary School MathMiddle School MathAlgebra 1GeometryAlgebra Pre-Calc/TrigCalculus 1Other
Summer Math Intensive – Hybrid (Grades 6–12)Saturday School (2nd–8th grade)Math Revolutions @ UCLA (2nd–8th grade)1-on-1 Tutoring (Premium Members or hourly rate $50/hour -members $100/hour non- members
Media Release & Liability Waivers
General Release of Liability:On behalf of myself and my minor child, I voluntarily release, discharge, indemnify, andagree to hold harmless B-RELYT/BMC and its officers, employees, agents, and representatives (“BMC Parties”) from any and all claims, liabilities, damages, losses,expenses (including attorney’s fees), or causes of action—known or unknown, anticipated or unanticipated, including those seeking equitable or declaratory relief—arising directly or indirectly from my child’s participation in programs offered by BMC Parties(“Release”). This Release is intended to be as broad and inclusive as permitted by law,and if any portion is held invalid, the remainder shall remain in full force and effect. I further expressly waive all rights under Section 1542 of the California Civil Code, which states:“A general release does not extend to claims that the creditor or releasing party does not know or suspect to exist in his or her favor at the time of executing the release, and that, if known by him or her, would have materially affected his or her settlement with the debtor or released party.”I understand that unknown or unforeseen facts may later arise but agree that this Release shall remain fully effective regardless of any such discoveries.Acknowledgment of Separate Waiver: I acknowledge receipt of, and agree to execute, any additional separate Release andWaiver of Liability for participation in specific BMC programs.Non-Refundable: I acknowledge and agree that all fees paid to B-RELYT/BMC are non-refundable. I further understand that B-RELYT/BMC is a nonprofit organization, and that payments made may be tax-deductible to the extent allowed by law.Media Release: I grant permission for BMC Parties to photograph or record my minor child duringprogram participation and to use such images and likeness in promotional or educationalmaterials or, if I wish to opt-out, by checking here, I agree that I will submit a writtenopt-out request to info@blackmathcollective.org prior to the start of the program. Myfailure to timely submit an opt-out request shall serve as my consent.Emergency Medical Consent: I authorize BMC Parties to administer first aid and, if necessary, seek emergency medicalcare for my child in the event of an injury during program activities.Field Trips: I understand that my child cannot participate in off-site activities unless I first execute aseparate permission form provided by BMC Parties.Behavioral Expectations: I understand that I will be notified if my child’s behavior interferes with the programsoffered by BMC Parties. Further disciplinary problems may result in expulsion from theprogram.Pick-Up Responsibility: I am responsible for ensuring my child is picked up promptly at the conclusion of eachscheduled program, event, meeting, or class, or session hosted by BMC Parties.No Liability: I acknowledge and agree that BMC Parties are not liable for any injury or harm that maybefall my child while traveling to or from any program, event, meeting, class or sessionhosted by BMC Parties.Arbitration/Mediation Agreement: I agree that any dispute related to this agreement or my child’s participation in programsoffered by BMC Parties will be resolved through final and binding arbitration withJAMS, rather than in court. I understand that this means giving up the right to a trial byjudge or jury. Before beginning arbitration, the parties agree to first attempt to resolveany dispute through good faith mediation administered by JAMS. If mediation does notresolve the dispute, it will be submitted to final and binding arbitration under the JAMSStreamlined Arbitration Rules. All disputes shall be governed by California law.
Signature & Date
Date*

MonthDayYear
Date
Signature*

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BMC Membership Benefits

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BMC Basic - Annual – $155 (One-time)

$155.00 for each year

Click this option of you would like to be invoiced Monthly or Bi-Weekly

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$50.00 for each year

BMC Premium - Annual – $361 (One-time)

$361.00 for each year

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Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Financial Assistance Request
I am unable to afford the $150 membership and would like to apply for financial assistance.
IF APPLICABLE* Please write a paragraph (3–5 sentences) explaining your current situation and why you're requesting assistance.
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The B-RELYT Organization, Inc dba B-RELYT Math Collective

B-RELYT Membership Registration and Registration 2025–2026 Programs

Overview

Parent/Guardian Information

Emergency Contact Information

Student Information

Media Release & Liability Waivers

Signature & Date

BMC Membership Benefits

Financial Assistance Request