Workshop Registration Form

Participant Registration Form

The Empowerment Workshop
Select the workshop you're applying for
Participants Name

First NameMiddle NameLast Name
Participants Birth Date

MonthDayYear
Parents Name

First NameLast Name
Parent Cell Number
Parent E-mail
example@example.com
Address

Address

APT #

CityState

Postal / Zip Code
EMERGENCY CONTACT

First NameLast Name
EMERGENCY PHONE NUMBER
Please enter a valid phone number.
Please print, complete & attach this waiver to your application.
UPLOAD your completed WAIVER here to complete your registration.

Thank you.
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Message to the program directors:
FOR ALL WORKSHOPS WITH A FEE - PLEASE PAY HERE. If your workshop is free, consider a donation, our Workshops are made possible by community support. Thank you!

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USDDonations are never expected & always appreciated!

Payment Methods

Debit or Credit Card

First Name

Last Name

Credit Card Number

Security Code

Card Expiration

Please click one of the PayPal options to complete payment and submit the form.

Participant Registration Form