Participant Registration Form
The Empowerment Workshop
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Please Select
Dirt Minions: MIDDLE SCHOOL /WAITLIST
Dirt Minions: 9-11 /WAITLIST
Dirt Minions Girls Only: 6-8 /WAITLIST
Participants Name
First Name
Middle Name
Last Name
Participants Birth Date
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Day
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Year
Parents Name
First Name
Last Name
Parent Cell Number
Parent E-mail
example@example.com
Address
Address
APT #
City
State
Postal / Zip Code
EMERGENCY CONTACT
First Name
Last 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.
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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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