2022 Program Registration

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 State

Zip Code
Person Attending *

First Name Last Name
Age *
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 *
How many people are supported by your Annual Household Income? *
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? *

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? *
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 *

USD E4G Registration Fees

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Should be Empty:

2022 Program Registration

Sorry, the program you've chosen is full!

Pre-Program Questionnaire