Empowerment Training Institute School Registration

Empowerment Training Institute School Registration

Fill out this form for class registration
The Empowerment Training Institute
Additional documents for registration Bring or email this registration form and the following documentation to the school office. • Current Proofs of Residence
Student Information
Name

First NameLast Name
M.I.
Birth Date

MonthDayYear
Gender
Ethnicity
Email Address
Entry Year You Start With Us
Highest Grade You Have Completed
Have you previously applied to or attended this school?

YesNo
If yes, what year?
Current Residence Information
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
Please list below, your desired programs and classes you wish to take with The Empowerment Training Institute and your desired outcomes training with us.
Please Tell Us About Yourself & What You Hope To Achieve

Emergency Contact Information
Name

First NameLast Name
Phone Number

Area CodePhone Number
Please list any of the following: Current medications, Medication allergies, Food allergies, Chronic health concerns.

Previous School 1
School Name
City
State
Date Started

MonthDayYear
Date Ended

MonthDayYear
Previous School 2
School Name
City
State
Date Started

MonthDayYear
Date Ended

MonthDayYear
Notes
Please inform the office of any other vital information you think they may need to know in the event of an emergency. Thank you.
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