Registration Form

Cadet's First Name*

Cadet's Last Name*

Cadet's Birth Date*

Race: (please select one)*

Parent/Guardian Name(s)*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email

Emergency Contact

Name (if primary guardian cannot be contacted or reached call…)

First Last

Phone – (if primary guardian cannot be contacted or reached call…)

Medical Information

You will need family/youth’s insurance card to fill out the information below.

Insurance Carrier

Policy Number

Family Doctor (Name)

Family Doctor (Phone)

Medical Information: Please enter medical fact requiring special attention (Diabetes, Epilepsy, Epi Pen, etc…)

Medication Information: Please enter any prescribed medication, dosage, and time administered

Medical Consent*

I (Parent/Guardian) agree to the Medical Consent.

Medical Consent
If I (Parent/Guardian) cannot be reached and/or in the event of a medical emergency, I (Parent/Guardian) give Boys II Men, Inc. permission to seek professional medical treatment for my child. (i.e. 911/Hospital/Urgent Care/etc.)

Academic Records

School*

Grade*

Please enter a number from 1 to 16.

Does your son have an Individual Education Plan (IEP)?*

Yes
No
Unknown

Will your son be the first to graduate from college from your immediate family?*

Yes
No
Unknown

Behavior Records

Has the potential cadet been suspended in the last calendar year?

No, potential cadet has not been suspended in the last calendar year
Yes, potential cadet was suspended in the last calendar year for violent behavior
Yes, potential cadet was suspended in the last calendar year for NONviolent behavior

Has the potential cadet been expelled in the last calendar year?

No, potential cadet has not been expelled in the last calendar year.
Yes, potential cadet was expelled in the last calendar year for violent behavior.
Yes, potential cadet was expelled in the last calendar year for NON-violent behavior.

Does the potential cadet have a juvenile court record?

No juvenile court record.
Yes, juvenile court record, but NOT currently under any court-ordered restrictions
Yes, juvenile court record, and currently under court-ordered restrictions

Transportation

Does your son have access to reliable transportation?

Yes
No

Residential Status

Current Housing Status

Homeowner
Renting
Occupying without rent or mortgage
Living with family
Experiencing unsheltered homelessness

Number of dependents under the age of 18 living with you

Is your son a 21st Century Scholar?*

Yes
No
Unknown

Family Status (please select one)*

Two Parent Household
Single Parent (Female)
Single Parent (Male)
Live with Relative/Guardian
Foster Care

Father Profile*

Active Father in home
Active Father not in home
In-Active Father in home
In-Active Father not in home
Never seen Father or deceased

Income section

Does your son receive free or reduced lunch?*

Yes
No
Unknown

Sources of income (check all that apply)

Annual Household Income (please select one)*

$0 – $20,000
$20,000 – $40,000
$40,000 – $60,000
$60,000 – $80,000
$80,000+

Marketing question and Disclosure statement

How did you find out about Boys II Men?*

Disclosure Statement Consent*

I (Parent/Guardian) agree to the Disclosure Statement.

Disclosure Statement
I hereby grant Boys II Men, Inc. the right and permission to use photographic portraits, pictures, video, audio recordings, and statistical data, that have been taken of or gathered on my child and myself or in which my child and myself may be included with others, for promotional or advertising use only. Boys II Men, Inc. may use, publish, and republish the same photographs or recordings as well as statistical data and anonymous personal information in whole or in part, individually, in any and all media and data now or hereafter, and for any purpose whatsoever, for illustration, promotion, art, editorial, advertising and trade, or any purpose whatsoever without restriction as to alteration; and to use my child and my name if Boys II Men, Inc. chooses.
Any information reported to a 3rd party in regards to my child and myself will be done so with my anonymity. I understand that Boys II Men, Inc. has the right to collect and report statistical data and analysis in a way that protects my child’s and my identity.

Optional question

Any additional information you would like Boys II Men to know about your son?

Email

This field is for validation purposes and should be left unchanged.