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MBI-PAL YAOD Scholar Registration Form
Please complete the online form below. Registration fee is $10 per year. Registration fee is due at Orientation or on First Day. Once you submit this form, we will process it and will be in contact by phone or email with more information.
Scholar Name
*
First
Last
Birthdate
MM
/
DD
/
YYYY
Age
*
Gender
Male
Female
Grade
KK
1
2  
3  
4  
5  
6  
7  
8  
9  
10  
11  
12  
What School Does Your Child Attend?
*
What is the Address of the School?
Parent/Guardian 1- Name
Relation to Child
Permanent Address
Phone
*
###
-
###
-
####
Phone Type
Please select
Cell
Work
Home
Email
Parent/Guardian 2- Name
Relation to Child
Permanent Address
Phone
###
-
###
-
####
Phone Type
Please select
Cell
Work
Home
Email
Emergency Contact Name
Emergency Contact Phone
###
-
###
-
####
Please list any allergies or dietary restrictions
Please list any medical conditions we should be aware of
Which program does your child have interest in?
Football (Boys Only) Ages 5-12
Volleyball (Girls Only) Ages 5-12
Cheerleading (Girls Only) Ages 5-14
Soccer Ages 5-12
Baseball Ages 5-12
Track & Field Ages 5-12
Basketball Ages 5-12
NFL Flag Football (Co-Ed) Ages 3-14
After-School Programs
Mentoring Ages 8-12
Mentoring Ages 13-18
SADD (Students Against Destructive Decisions) Ages 13-18
MAP (Memphis Ambassador Program) 9th-12th graders
Yes
No
Transportation: We will be able to provide transportation to a limited number of scholars that attend schools within a 10-mile radius of our center. Note: transportation not available for summer program. Would you like more info about this?
If not using our transportation, please share how your child will get to the program.
I am interested in:
After Care
Summer Program