2026–2027 Application | Black Male College Explorers

Step 1 of 4

Participant information

Tell us about the young man applying to the program.

Participant name

First name Middle name Last name

School name Current grade level Date of birth AgeCalculated from date of birth. Adult T-shirt size

Step 2 of 4

Parent or guardian

Program correspondence will be sent to this address unless you tell the team otherwise.

Parent or guardian full name Street address City State ZIP code Home phone Cell or primary phone Email address

Local contact Optional, if different from above

Full name Relationship to participant Street address Home phone Cell phone Email address

Step 3 of 4

Emergency & medical information

This information helps program staff respond appropriately if a parent or guardian cannot be reached.

Emergency notification card

Mother’s name Mother’s cell or primary phone Father’s name Father’s cell or primary phone Guardian’s name Guardian’s cell or primary phone

Medical information

A

Does the participant have an allergy to insect stings?

Yes No

B

Does the participant have an allergy to penicillin or particular serums?

Yes No

C

Does the participant have diabetes?

Yes No

D

Does the participant have epilepsy?

Yes No

E

Are there other allergies or disabilities BMCEP should know about?

Yes No

F

Is there another health condition, mental or physical limitation that may affect participation?

Yes No

Physician and temporary care contacts

Family physician’s name Physician’s phone Comments Temporary care contact 1 name Temporary care contact 1 phone Temporary care contact 2 name Temporary care contact 2 phone

Step 4 of 4

Consent & electronic signatures

Read each statement carefully. The parent or legal guardian must sign both sections.

Electronic signature disclosure

By checking the box below and selecting “Submit signed application,” you agree to use electronic records and signatures for this application. You understand that typing your name is your electronic signature and shows your intent to sign. The private submission record includes the signed terms, date and time, IP address, and browser information to document the signing event.

I consent to electronic records and signatures and intend to sign this application electronically.

Take the next step.

Participant information

Parent or guardian

Emergency & medical information

Consent & electronic signatures

Electronic signature disclosure