EnrollmentForm

Salutation

First Name:

Surname

Street Address

City

State

Zip Code or Postal Code:

Choose BMMP City:

Neighborhood Area Name:

My income is 35K or less.

Please tell us what are some of your most important personal goals and aspirations and why you

would like to be selected to be in this BMMP? (Window

What are your family-community goals?

What are your greatest internal and external challenges?

I certify that I am and have been drug free for at least one year from the date of this application:

Upload 3rd party testimonies that you've been drug free for 1 year or more. You may also FAX them to 1-815-366-8133 or mail them to BMMP 1083 Columbia Drive Decatur, GA 30030

Drug Free:

Challenges:

Who speaks for you?

To participate in the BMMP program you must have three (3) people who will recommend you.
Three people who will say why they recommend that we accept you into the program. Their letter should
speak about your strengths and weakness.
Who:
*One from an older family member who is not already enrolled in the program
*One from a community leader, activist, teacher, counselor or minister
*One from a peer (someone of your own age-group or generation)
These statements must be signed and include full name, titles (if any) name, address, phone and email.

If you are on parole, please list your parole officers name and contact information below:

Upload 3rd party testimonies that you've been drug free for 1 year or more. You may also FAX them to 1-815-366-8133 or mail them to BMMP 1083 Columbia Drive Decatur, GA 30030

Goals:

Enrollment Form