Young Brilliant Minds

Member Registration Form

Member Name:

Mailing Address

City/Town:

State:

Zip code:

Member Email:

Member Cell Phone:

T-shirt Size: XS S M L XL 2X 3X

Parent(s) Name:

Parent(s) Cellphone:

Parent(s) Email

*Disclaimer: By completing this form, member & parent(s) of member agree that the Black membership T-Shirt will be mailed within 7 business days.

Contact # 305-793-9038 / 305-766-1346

PO Box 540082, Opa Locka, Fl. 33054

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