2022 Program Registration
Please indicate which program you're registering for, then select the correct date. **This form is for one program and for one child. Separate program registration forms must be filled out for additional registrants or programs.
Which program is this registration for: Conscious Minds Conscious Bodies (CMCB) or Empowerment?
*
CMCB
Empowerment
Choose the correct program date
*
July 18-22 - Empowerment weeklong
August 15-19 - CMCB weeklong
Aug 29 - Sept 2 - Empowerment weeklong
November 5 - CMCB
December 17 - Empowerment
Sorry, the program you've chosen is full!
Proceed and finish the form to be placed on a waiting list or choose another program
Parent or Guardian
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
Confirmation Email
Please enter email twice for verification
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Person Attending
*
First Name
Last Name
Age
*
Please Select
9
10
11
12
13
14
15
16
Birthdate
*
-
Month
-
Day
Year
Date
Is this child in the foster care system?
*
Yes
No
Pre-Program Questionnaire
Please take a moment and answer the following questions. All information provided will be stored securely. Personal information will only be shared with Empowerment 4 Girls Program staff and pre-screened camp volunteers, as needed.
Dietary Restrictions
*
Food Preference
*
Vegan
Vegetarian
Meat Eater
3. Does your child have any medical conditions or other health restrictions? Are they on any medications?
*
Annual Household Income
*
Please Select
$0-$16,910
$16,911-$25,750
$25,751-$34,590
$34,591-$43,430
$43,431-$51,500
$51,501-$60,340
$60,341-$69,180
$69,181-$77,250
$77,251-$86,860
$86,861-$103,770
$103,771-$117,030
$117,031-$130,290
$131,291-or more
How many people are supported by your Annual Household Income?
*
Please Select
2
3
4
5
6
7
8
9
10
Racial Makeup of Household - Choose all that apply
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or other Pacific Islander
White
Does your child exhibit any behavioral, emotional or developmental challenges?
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Anxiety
Depression
Suicidal Thoughts or Expression
Aggression Toward Others
Self-Harm
Learning Disabilities
None of the Above
Please explain the above choices.
*
How do you think this program will benefit your child and your household?
*
What are some of the expectations you have in your child attending this program?
*
Positive Body Image
Become More Empowered
Increase Confidence
Puberty/Menstruation Education
Gender Identity/Sexual Orientation
Building Healthy Relationships
Consent/Boundaries
Resiliency
Stress Reduction
Spiritual Growth
Connecting with Others
Social Media Awareness
Needed a Place for My Child
Other - Please Explain Below:
Please explain Other expectations
How did you hear about us?
*
Please Select
Google Search
Google Ad
Facebook
LinkedIn
Friend or Family Member
Other
Are you applying for a Scholarship?
*
Yes
No
Would you like to place a deposit or pay in full?
*
Deposit
Pay in full
Balance
Payment Amount Calculation
Remaining Balance Due
Payment Amount
*
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USD
E4G Registration Fees
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
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