BMIT/BWIT Registration

1
Which organization are you registering for?* This field is required.Black Men In Training (BMIT) Black Women In Training (BWIT)
BMIT
BWIT
2
Registration Date* This field is required.(date of submission)
Date
Month
Day
Year
3
Youth Name* This field is required.
First Name
Last Name
4
Youth DOB* This field is required.
Date
Month
Day
Year
5
Youth Age* This field is required.Must be age 5-24
6
Youth Ethnicity* This field is required.
7
School Name and Grade Level* This field is required.
8
Favorite Hobbies* This field is required.
Huge
Large
Normal
Small
Ok
Ok
9
Areas of Concern* This field is required.
Huge
Large
Normal
Small
Ok
Ok
10
Allergies/Health Conditions* This field is required.
Huge
Large
Normal
Small
Ok
Ok
11
Anything else you think we should know?
Huge
Large
Normal
Small
Ok
Ok
12
Are Both Parents Present in Household?* This field is required.
Please Select
Please Select
Yes
No – Only a Mother is present
No – Only a Father is present
No, but has a positive MALE/FEMALE role model or Stepparent
Father is Deceased or Incarcerated
Mother is Deceased or Incarcerated
13
Contact Info:Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
14
Contact Info:* This field is required.Cont.
Parent/Guardian First Name
Parent/Guardian Last Name
Phone Number
Email
Emergency Contact
Phone Number
15
Contact Info:Cont. 2
Parent/Guardian First Name #2
Parent/Guardian Last Name #2
Phone Number
Email
Emergency Contact
Phone Number
16
Uniform (Shirt Size)* This field is required.
Please Select
Please Select
Youth-XS
Youth-S
Youth-M
Youth-L
Youth-XL
Adult-S
Adult-M
Adult-L
Adult-XL
Adult-XXL
17
Photo Release Form* This field is required.We request your permission to take photographs/videos of the B.M.I.T Program. These photographs/videos may become a part of B.M.I.T.'s portfolio and will be used for recruitment and informational purposes only.
Yes Agree
No Disagree
18
Signature* This field is required.
Should be Empty: