BTM NEW CHILD APPLICATION $10 monthly
"A STEP IN THE RIGHT DIRECTION" PLEASE FILL OUT COMPLETELY

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Email address *
Child's Full Name *
Your answer
Child's Age *
Parent/Gaurdian's Name *
Your answer
Childs Birth Date *
MM
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DD
/
YYYY
Home Phone *
Your answer
Cell Phone *
Your answer
School Child Attends *
Your answer
Home Address *
Your answer
City *
Your answer
State
Number Of Family In Home
Name/Relationship
Your answer
Name/Relationship
Your answer
Name/Relationship
Your answer
Emergency Contact 1 (Name and Number) *
Your answer
What type of medical insurance? *
If Personal health insurance, please name the insurance
Your answer
Child's Hobbies/Interests
Your answer
Child's Special Needs
Your answer
Organizations you are affiliated with
Your answer
Services you are currently using
Your answer
Explain why would you like your child to become involved in Boys to Men Foundation *
Your answer
Date you would like to start
MM
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DD
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YYYY
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