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* -Month -DayYearDate Age* Gender* MaleFemale School Name Grade Level Home Address Street Address Street Address Line 2CityState / ProvincePostal / Zip Code Please Select Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan The Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Curaçao Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Polynesia Gabon The Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Nagorno-Karabakh Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Turkish Republic of Northern Cyprus Northern Mariana Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Republic of the Congo Romania Russia Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia Somaliland South Africa South Ossetia South Sudan Spain Sri Lanka Sudan Suriname Svalbard eSwatini Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Transnistria Pridnestrovie Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam British Virgin Islands Isle of Man US Virgin Islands Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Other Country City State Parent/Guardian Information Parent/Guardian Full Name* First NameLast Name Relationship to Participant* Please Select Mother Father Guardian Grandparent Aunt/Uncle Sibling Other 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 & FitnessLeadership DevelopmentViolence PreventionWorkforce DevelopmentEntrepreneurshipMental WellnessCommunity OutreachMedia & Content CreationField Trips & Community ActivitiesMentorship Boxing & Fitness Yes Leadership Development Yes Violence Prevention Yes Workforce Development Yes Entrepreneurship Yes Mental Wellness Yes Community Outreach Yes Media & Content Creation Yes Field Trips & Community Activities Yes Mentorship Yes Communication Opt-Ins Text message updates from Be The Proof Foundation and B.L.O.C.S.C.* I agree Email updates, program announcements, and community opportunities* I agree Signatures Parent/Guardian Digital Signature* Date* -Month -DayYearDate Participant Signature* Staff Use Only Security & Submission Verify you are human* Electronic Signature* Consent to submit this form* I confirm the information provided is accurate and I consent to submit this form SubmitSubmit Should be Empty:
