Donate NOW

Member Registration

Building Hope Inspiring Change (BHIC) Youth Member Registration Form

Welcome to BHIC! We are thrilled to have you join our community of inspiring youth. Please complete the following registration form to become a member.

    Personal Information

    First Name:

    Last Name:

    Date of Birth:

    Age:

    Gender:

    Street:

    City:

    State:

    Zip Code:

    Contact Information

    Phone Number:

    Email Address:

    Preferred Method of Contact:

    Parent/Guardian Information

    Parent/Guardian Name:

    Relationship to Youth Member:

    Phone Number:

    Email Address:

    Emergency Contact Information

    Emergency Contact Name:

    Relationship:

    Phone Number:

    Medical Information

    Allergies or Medical Conditions:

    Medications Currently Taking:

    Interests and Goals

    Hobbies and Interests:

    Academic or Personal Goals:

    BHIC Programs Interested In:

    Additional Information

    How did you hear about BHIC?

    Anything else you would like us to know?

    Consent and Acknowledgment

    Together, we can build hope and inspire change in our community.
    Donate now
    event registration

    Quick Link

    Find Us Here​

    • 105 W Michigan Ave. Ypsilanti Mi, 48197
    • 734-320-4819
    • Info@bhicinc.org

    Newsletter

    Stay connected and inspired by subscribing to our newsletter!


      Copyright © 2024 BHIC Inc. All Right Reserved.

      Facebook Instagram Twitter Linkedin
      Shopping Cart
      Scroll to Top