BLACK MEN IN TRAINING
MEMBERSHIP APPLICATION
Date
-
Month
-
Day
Year
Date
Child Name
*
First Name
Last Name
D.O.B
*
-
Month
-
Day
Year
Date
Age
*
School
*
Grade
*
Favorite Hobbies
*
Areas Of Concern
*
Is Father Present in Child’s Life?
*
Yes
No
No, but has a positive MALE role model or Step Father
Father is Deceased or Incarcerated.
Allergies/Health Conditions
*
Contact Info:
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of Parent/Guardian
*
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Emergency Contact
*
Name/Relationship
Phone Number
*
-
Area Code
Phone Number
Uniform (Shirt Size)
*
Youth-XS
Y-S
Y-M
Y-L
Y-XL
Adult-S
A-M
A-L
A-XL
A-XXL
Y=Youth A=Adult
Photo Release Form
We request your permission to take photographs/videos of the B.M.I.T Program. These photographs/videos may become apart of B.M.I.T portfolio. They will be used for recruiting and informational purposes only.
Yes Agree
No Disagree
Signature
*
Submit Membership
Signature Date
*
-
Month
-
Day
Year
Date
Should be Empty: