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
Format: (000) 000-0000.
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.Format: (000) 000-0000.
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!

Debit or Credit Card

Choose from one of the PayPal options to make your payment.

Participant Registration Form