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Program Registration

Program Registration

If you need more assistance with other inquires, please fill out the contact us form. (No mobile information will be shared with third parties/affiliates for marketing/promotional purposes.)

100 Black Men of Metropolitan St. Louis, Inc. Program Registration

Student Information

STUDENT Email Address (**Different from Parent Email** if student does not have an email address, please use STUDENTfirstname.STUDENTlastname@gmail.com)

Student T-Shirt/Polo Size
Birthday
Grade level at time of registration
Projected High School Graduation Year
Projected College Graduation Year
Does your student have an IEP/504?
Yes
No
Allergies
Yes
No
Medical Conditions

Student Demographic Information

Please mark your responses to the questions below. Your responses to the questions below help 100 Black Men of Metropolitan, Inc. to know more about the youth we serve and do not impact the student's eligibility to participate in this program.

What is the student's primary household status?
Two Parent
Single Parent Household (Female)
Single Parent Household (Male)
Grandparent(s)
Other
Student's Gender
Male
Female
Other
Student's Race/Ethnicity
Does your student receive free or reduce lunch?
Yes
No
What is the income range for your household?
$0 - $15,000
$25,000 - $45,000
$45,000 - $65,000
$65,000 or higher
What county does your student live in most of the year?
Has the student been suspended or expelled from school in the last 12 months?
Yes
No
Has the student ever had contact with the juvenile justice truancy court or the criminal justice system?
Yes
No
Unsure
Please select the 100 Black Men Programs the student is interested in participating:
How did you hear about this Program?

Primary Parent/Guardian Information

Relationship to Student