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2022 Registration: FBB Literacy & Education
Registration Form 2022
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Today's Date
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MM
/
DD
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YYYY
Participant's Name:
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Your answer
Participant's Phone Number
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Your answer
Parent/Guardian Name:
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Your answer
Parent/Guardian Phone Number
Your answer
New or Returning Participant
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New Participant
Returning Participant
Address: Street, City, State and Zip Code
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Your answer
Parent's E-Mail Address:
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Your answer
County
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Coahoma
DeSoto
Tunica
Other
Participant's Sex:
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Male
Female
Participant's Age:
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3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
Participant's Date of Birth
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MM
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DD
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YYYY
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
Number of Parents in household?
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1
2
Parent's Date of Birth
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MM
/
DD
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YYYY
Household Annual Income:
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$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
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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:
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Pre-K
K
1
2
3
4
5
6
7
8
9
10
11
12
College Freshman
College Sophomore
College Junior
College Senior
College Graduate School
Shirt Size
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YS
YM
YL
YXL
YXXL
AS
AM
AL
AXL
AXXL
Pants Size
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YS
YM
YL
YXL
YXXL
AS
AM
AL
AXL
AXXL
Emergency Contact Name (other than parent/guardian)
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Your answer
Emergency Contact Telephone (other than parent/guardian)
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Your answer
Emergency Contact Relationship
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Your answer
I agree that my child(ren) will attend group and one-on-one sessions with a mentoring coach. (1.5 hours required per week)
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Yes
No
I agree to take pictures and videos of my child(ren) upon request.
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Yes
No
Family Biz Builder promotes the organization on social media (website, Facebook, Instagram, Twitter and LinkedIn). I agree that my player's photos can by published online.
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Yes
No
I understand that Family Biz Builder will not be held responsible for any inappropriate use of internet sites while participating in Biz Builder Program trainings.
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Yes
No
I agree to participate in parent meetings and training courses.
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Yes
No
Are you interested in working part-time as a Mentoring Coach?
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Yes
No
Would you like to be a Volunteer in the Literacy & Education Program?
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Yes
No
Parent/Guardian Electronic Signature
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