B.L.O.C.S.C Youth Registration & Waiver Form

B.L.O.C.S.C Youth Registration & Waiver Form

Building Leaders On Community and Social Change
Participant Information
Participant Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Age
Gender
School Name
Grade Level
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
City
State
Parent/Guardian Information
Parent/Guardian Full Name

First NameLast Name
Relationship to Participant
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Emergency Contact Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Emergency Contact
Health & Medical Information
Allergies
Medical Conditions
Medications
Insurance Provider
Physician Name and Number
Confirmation of Physical Ability to Participate

I confirm the participant is physically able to participate
Additional Medical Notes
Program Interests
Program Interests
Boxing & Fitness
Leadership Development
Violence Prevention
Workforce Development
Entrepreneurship
Mental Wellness
Community Outreach
Media & Content Creation
Field Trips & Community Activities
Mentorship
Communication Opt-Ins
Text message updates from Be The Proof Foundation and B.L.O.C.S.C.
Email updates, program announcements, and community opportunities
Signatures
Parent/Guardian Digital Signature
Date

MonthDayYear
Date
Participant Signature
Staff Use Only
Security & Submission
Verify you are human
Electronic Signature
Consent to submit this form
Should be Empty: