Register Your Child

BMMU Master Youth Registration, Parental Consent and Waiver Form

Black Muslim Men United for a Better Philadelphia BMMU Master Youth Registration & Consent Portal

Participant Information

Please provide the details of the youth participant.

First Name

Last Name

Date of Birth

Age

Gender

Participant Email (If applicable)

Home Address

Street Address

Address Line 2

City

State

ZIP Code

Country

School

Grade Level

Parent / Legal Guardian Information

Primary contact details for parent or legal guardian.

First Name

Last Name

Relationship to Participant

Email Address

Emergency Contact (Other than Parent/Guardian)

Backup contact in case primary parent/guardian cannot be reached.

Emergency Contact Name

Relationship to Participant

Health & Medical Information

Please declare any medical conditions, allergies, or medications to help us keep your youth safe.

Does the participant have any allergies?

Yes

Allergy Details

Does the participant have any medical conditions?

Yes

Medical Condition Details

Is the participant currently taking any medications?

Yes

Medication Details

Consent Agreements & Liability Waiver

Please read carefully and check each box to authorize participation.

Emergency Medical Care Authorization

I hereby authorize BMMU staff, volunteers, and medical professionals to administer emergency medical treatment to my child if necessary during program activities. I understand every effort will be made to contact me immediately.

Parental Consent for Program Participation

I give full consent for my child to participate in all scheduled programs, mentorship sessions, workshops, and community events organized by Black Muslim Men United for a Better Philadelphia (BMMU).

Photography, Video & Media Authorization

I grant permission to BMMU to take and use photographs, video recordings, or digital media of my child for promotional, educational, or community-awareness purposes across official websites and social media.

Assumption of Risk Waiver & Release

I assume all risks associated with my child's participation in BMMU programs. I release, waive, and discharge Black Muslim Men United for a Better Philadelphia, its board, staff, and volunteers from any and all liability, claims, or demands arising out of injury, damage, or loss.

Continuing Registration Acknowledgement

I acknowledge that this registration remains active for the duration of the current program cycle, and I agree to update BMMU immediately in writing of any changes to contact, health, or emergency information.

Digital Signature

By checking the box below and typing your name, you are providing a legally binding digital signature.

I confirm that I am the parent or legal guardian of the registered youth, and all information provided is accurate and true.

Parent/Guardian Digital Signature

Date of Signature

Participant Information

Parent / Legal Guardian Information

Emergency Contact (Other than Parent/Guardian)

Health & Medical Information

Consent Agreements & Liability Waiver

Digital Signature

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