F2B1

Intake Form

BMIT Program Interest*
Parent or Guardian Name*
Parent or Guardian Email*
Parent or Guardian Phone #*
Household Income*
Household Size*
Emergency Contact Name*
Emergency Contact Phone*
Participant Information

DOB*
AGE*
Racial Identity*
Pronouns*
School of attendance (If none, enter N/A)*
Grade (If none, enter N/A)*
What your interests? How do you spend yourtime?*
Other interests not listed above
What are some behaviors that concern you?*
List any health conditions*
Known Allergies*
Food Sensitivities*
Do you have any disabilities?*
Military status?*
Do you have health insurance?*
Select T-Shirt Size*
Photo Release*
Participant Initials
Participant Initials Date
Guardian Initials*
Guardian Initials Date*