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2024 Registration: FBB College & Career Readiness
Registration Form 2024
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Email
*
Your email
Today's Date
*
MM
/
DD
/
YYYY
Participant's Name:
*
Your answer
Participant's Phone Number
*
Your answer
Parent/Guardian Name:
*
Your answer
Parent/Guardian Phone Number:
Your answer
Street Address:
*
Your answer
City:
*
Your answer
State:
*
Your answer
Zip Code:
*
Your answer
Parent's E-Mail Address:
*
Your answer
County
*
Choose
Coahoma
DeSoto
Tunica
Other
Participant's Gender
:
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Male
Female
Participant's Age:
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Choose
12
13
14
15
16
17
18
19
20
21
22
23
24
Race
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African American
Caucasian
Hispanic
Other
Number of People in Household?
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1
2
3
4
5
6
7
8
9
10
Check all adults in the household: (above the age of 18)
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Mother
Father
Grandparent
Guardian
Other:
Required
Household Annual Income:
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Choose
$0-10,000
$10,001-30,000
$30,001-50,000
$50,001-70,000
$70,001-90,000
$90,001-120,000
$120,001-200,000
$200,001-300,000
$300,001+
School
*
Choose
Clarksdale Collegiate
Desoto Central Middle School
Dundee Elementary
Horn Lake Intermediate
Kirkpatrick Health and Science Magnet
Lake Cormorant Elementary
Lake Cormorant Middle
Lake Cormorant High School
Presbertyrian Day School
Robinsonville Elementary
Rosa Fort High School
Tunica Elementary
Tunica Middle School
Walls Elementary School
Other
Grade:
*
Choose
5
6
7
8
9
10
11
12
College Freshman
College Sophomore
College Junior
College Senior
College Graduate School
Anticipated Graduation Year
*
Choose
2024
2025
2026
2027
2028
2029
2030 or later
Academic Areas of Challenge
*
English
Math
Reading
Science
Writing
ACT
SAT
Required
Have you ever participated in a Family Biz Builder in-school and after-school program
*
Choose
No
Yes
I agree that my child(ren) will attend group and one-on-one sessions with a mentoring coach. (at minimum 1.5 hours per week required)
*
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Yes
No
Family Biz Builder promotes the organization online (via website, Facebook, Instagram, LinkedIn and YouTube). I agree that any program videos recorded or photos taken can by published online.
Choose
Yes
No
I understand that Family Biz Builder will not be held responsible for any inappropriate use of internet sites.
*
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Yes
No
I agree to participate in parent meetings and training courses.
*
Choose
Yes
No
Are you interested in working part-time as a Mentoring Coach?
*
Choose
Yes
No
Would you like to be a Volunteer in the College & Career Readiness Program?
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Choose
Yes
No
Parent/Guardian Electronic Signature
*
Your answer
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