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100 Black Men of Indianapolis Financial Literacy Program

2023-24 Enrollment Application

Date/Time

Student Information

Student's Name*

First Name

Last Name

Student's Email*

Students's Phone*

Student T-shirt/Polo Size

Select Your Student Size

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Birthdate*

Grade level at time of registration*

Projected High School Graduation Year*

Projected College Graduation Year *

Current School Name*

K - 7th Pass/ Fail

Pass (Move next grade level ) Fail (Held back)

Current GPA

Student Phone*

Allergies

Yes No

List of Allergies/Dietary Restriction

Allergies description

Asthma*

Yes No

Medical Conditions*

List Any Other Medical Information We Should Be Aware Of

Upload an Individual Professional Photo of Your Student*

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Student Profile Image

Primary Parent/Guardian Information

Primary Parent/Guardian Name*

First Name

Last Name

Relationship to Student*

Parent Aunt/Uncle Grandparent Other

Parent/Guardian Email*

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Primary Phone

Phone Type

Alternate Phone

Alternate Phone Type

Secondary Parent Information

Secondary Parent/Guardian Name

First Name

Last Name

Relationship to Student

Parent Aunt/Uncle Grandparent Other

Secondary Parent/Guardian Email

Address

Address Line 1

Address Line 2

City

State

ZIP Code

Medical Information

Name of Doctor

Prefix (optional)

First Name

Last Name

Insurance Company

Policy Number

Emergency Contact Information

Emergency Contact Name*

First Name

Last Name

Emergency Contact Relationship to Student*

Parents Aunt/Uncle Grandparent(s) Other

Emergency Contact Email*

Emergency Contact Phone*

Please Read and Initial the Items Below To Acknowledge Your Consent

I authorize and release 100 Black Men of Indianapolis, Inc. to use images of my student and/or myself (including motion pictures, still images, or sound recordings of my or my student's voice made by 100 Black Men of Indianapolis, Inc.) ("Images") for any purposes in connection with promoting 100 Black Men of Indianapolis 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.*

Initial required

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

Initial required

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.*

Initial required

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.*

Initial required

Authorization

Student's Signature*

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Parent's Signature*

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100 Black Men of Indianapolis Financial Literacy Program

2023-24 Enrollment Application

Student Information

Student Demographic Information

Primary Parent/Guardian Information

Secondary Parent Information

Medical Information

Emergency Contact Information

Please Read and Initial the Items Below To Acknowledge Your Consent

Authorization