*
*
*
*
*
*
*
*
*
*
Intake Form
BMIT Program Interest
*
Parent or Guardian Name
*
Parent or Guardian Email
*
Parent or Guardian Phone #
*
Household Income
*
-
$0-$30k
$31-$55k
$56-$80k
$81k+
Household Size
*
Emergency Contact Name
*
Emergency Contact Phone
*
Participant Information
DOB
*
AGE
*
-
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
Racial Identity
*
-
American Indian/Alaskan Native
Asian
Black/African American
Hispanic
Latino
Middle Eastern/North African
Multiracial
Native Hawaiian/Pacific Islander
Other
White
Pronouns
*
-
he/him
she/her
they/them
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?
*
-
No
Yes
Military status?
*
-
Active Duty
Not Active Duty
Veteran
Do you have health insurance?
*
-
No
Yes
Select T-Shirt Size
*
-
A-2XL
A-L
A-M
A-S
A-XL
Y-L
Y-M
Y-S
Y-XL
Y-XS
Photo Release
*
-
No
Yes
Participant Initials
Participant Initials Date
Guardian Initials
*
Guardian Initials Date
*
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
Powered by Sumac Nonprofit CRM Software
version 7.4.17