Girl Empowerment After School Online Registration

Flourish Online 2025/2026 Registration After School Program

To register your child for our FLOURISH after school empowerment program please complete the form below. We'll send confirmation email confirming registration. For more information please visit our website at www.empoweretoflourish.com.
Parent / Guardian Full Name*

First NameLast Name
Parent's E-mail*
Parent/ Guardian email ex. Janedoe@example.com
Cell Phone Number*
Recieve Text Updates
Receive updates via*

Text MessageEmailText Message + Email
Cell Phone Number*

Area Code (xxx)Phone Number xxx-xxxx
Name of Student*

Student First NameStudent Last Name
Grade of participant?*

4th grade5th grade6th grade7th grade8th grade9th grade10th grade11th grade12th grade
Grade of participant?
Participant Age*
Girls ages 9-14
School Attending*
Current School
Student T-Shirt Size (Losse fit)*
T-shirts are true to size
First time attending an E2F After School Program?*

YesNo
Would you like to volunteer at the program?*

Yes, tell me more.Yes, I can donate chips or water.Yes, at the end-of-year celebration.No, not at this time.Yes, join our Mama Bears Crew.
What areas would you like your child to improve in?

Positive Self-esteemOvercoming Peer PressureSelf-confidenceFocus/Goal settingEmotional WellnessBehaviorOther
Parent Comments:
What should we know about your child.
Emergency Contact*

First NameLast Name
Emergency Contact Cell Phone*

Area CodePhone Number
Emergency Contact Relationship to child*
Must be 18 years old to list as emergency contact
I hereby request and consent that my child or dependent your child's name here be permitted to participate in Empowered to Flourish after school program. I further understand that this program is designed to enhance self concept by guiding at-risk females in self-awareness, self-esteem and self-confidence and that my child will be required to attend and engage in program.

I agree to media post unless otherwise specified.

IParent Full Name and Child First Name Child Last Name (child's name) pledge to follow all conduct rules and
acknowledge that my failure to obey rules and requirements may result in my removal from the program.
Signature*

Clear
Should be Empty:

Flourish Online 2025/2026 Registration After School Program