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Program Registration

Program Registration

If you need more assistance with other inquires, please fill out the contact us form. (No mobile information will be shared with third parties/affiliates for marketing/promotional purposes.)

100 Black Men of Metropolitan St. Louis, Inc. Program Registration

Student Information

STUDENT Email Address (**Different from Parent Email** if student does not have an email address, please use STUDENTfirstname.STUDENTlastname@NOmail.com)

Student T-Shirt/Polo Size
Birthday
Grade level at time of registration
Projected High School Graduation Year
Projected College Graduation Year
Does your student have an IEP/504?
Yes
No
Allergies
Yes
No
Medical Conditions

Student Demographic Information

Please mark your responses to the questions below. Your responses to the questions below help 100 Black Men of Metropolitan, Inc. to know more about the youth we serve and do not impact the student's eligibility to participate in this program.

What is the student's primary household status?
Two Parent
Single Parent Household (Female)
Single Parent Household (Male)
Grandparent(s)
Other
Student's Gender
Male
Female
Other
Student's Race/Ethnicity
Does your student receive free or reduce lunch?
Yes
No
What is the income range for your household?
$0 - $15,000
$25,000 - $45,000
$45,000 - $65,000
$65,000 or higher
What county does your student live in most of the year?
Has the student been suspended or expelled from school in the last 12 months?
Yes
No
Has the student ever had contact with the juvenile justice truancy court or the criminal justice system?
Yes
No
Unsure
Please select the 100 Black Men Programs the student is interested in participating:
How did you hear about this Program?

Primary Parent/Guardian Information

Relationship to Student
Primary Phone Type
Alternate Phone Type

Secondary Parent Information

Secondary Parent Relationship to Student

Emergency Contact Information

Emergency Contact Relationship to Student
Parents
Grandparent(s)
Aunt/Uncle
Other

Please Read and Initial the Items Below To Acknowledge Your Consent

I authorize and release 100 Black Men of Metropolitan St. Louis, Inc. to use images of my child and/or myself (including motion pictures, still images, or sound recordings of my or my student's voice made by 100 Black Men of Metropolitan St. Louis, Inc.) for any purposes in connection with promoting 100 Black Men of Metropolitan St. Louis, Inc. and its programs which may include advertising, fundraising, promotion and marketing, and social media. I understand that I will receive no payment for the use of these images in which my student(s) or I may appear.*

I hereby release 100 Black Men of Metropolitan St. Louis, Inc., its employees, staff, volunteers, and agents from any and all liability for injuries to my child/ward, except for injuries caused by the intentional acts of employees, staff, volunteers, and agents.*

I currently have and agree to maintain throughout the time my child participates in the program, valid and sufficient medical and accident insurance.  I agree that it is my responsibility to provide this coverage for my child.  If my child is injured and requires medical care I consent to such care.

I, the Parent/Guardian of the program participant, have read the attached material and give my permission for him/her to participate in the program and any related activities including travel to designated cultural and educational events.

Authorization

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