Black Homeschoolers of Birmingham Membership Enrollment Form
New Family Registration form *ALL responses are kept confidentially, and only seen my BHOB Board of Directors. (Biographical and Financial questions asked only to collect data, so please be honest in your responses).

DO NOT WRITE IN THIS SECTION 
Black Homeschoolers of Birmingham Membership Enrollment Form
Membership Structure
  • Free 
  • Basic
  • Basic Monthly Membership $19.99 per month 
  • Basic Annual Membership $199.99

  • Premium
  • Basic Monthly Membership $39.99
  • Premium Annual Membership $399.99
Payment link 
    

Sign in to Google to save your progress. Learn more
Email *
Parent 1 Name *
Parent 1 Phone Number *
Parent 2 Name (If not applicable state N/A below)
Parent 2 Email (If not applicable state N/A below)
Parent 2 Phone Number  (If not applicable state N/A below)
Emergency Contact Information (name, number, email address and relationship to child/children)
Race/Ethnicity *
Combined Household Income  *
Student 1 Name 
 *
Student 1 Gender
 *
Student 1 Date of Birth
 *
Student 1 Grade 
 *

Student 1 Allergies/Medical Conditions
 *
Student 2 Name
Student 2 Gender
Clear selection
Student 2 Date of Birth
Student 2 Grade 
Student 2 Allergies/Medical Conditions
Student 3 Name
Student 3 Gender
Clear selection
Student 3 Date of Birth
Student 3 Grade 
Student 3 Allergies/Medical Conditions
Student 4 Name 
Student 4 Gender
Clear selection
Student 4 Date of Birth
Student 4 Grade 
Student 4 Allergies/Medical Conditions
Student 5 Name
Student 5 Gender
Clear selection
Student 5 Date of Birth
Student 5 Grade  
Student 5 Allergies/Medical Conditions
Student 6 Name
Student 6 Gender
Clear selection
Student 6 Date of Birth
Student 6 Grade  
Student 6 Allergies/Medical Conditions
Next
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms