EmpowHERing Minds Academy 2024 Registration

Welcome to EmpowHERing Minds Academy 2025-2026 Enrollment Year!

Please carefully read each question and make sure the information you provide is complete and accurate.

Enrollment fee is $100 which helps to cover program materials, paraphenelia, awards, and activities.

Please call (662) 932-1360 or email us at emi@empowHERingminds.org with any questions.
Name*

First NameLast Name

Personal Information
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
E-mail*
Please enter the email for the participant.
Birthday*
Tshirt Size*
Referred By:

First NameLast Name

Parent/Guardian Information
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Address (if different than member)

Street Address

Street Address Line 2

CityState

Zip Code
E-mail*
Please enter an email for parent of participant.

Education
School name*
Current Grade*
Year
Graduation Year*
Year
Are you participating in any other mentoring program? If yes, please indicate.*

YesNo
If yes, please list
What are you hoping to gain from the EmpowHERing Minds Academy?*

0/250

Primary Contact Name*

First NameLast Name
Emergency Contact Information

This information is used in the event of an accident or medical emergency
Address Same As Above*

YesNo
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*

Area CodePhone Number
Relationship*
Secondary Contact Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number

Area CodePhone Number
Relationship
In the event that persons above are unable to be contacted, please complete the following:
Insurance Comapany
Policy #
Primary Member
Member ID
Include any special medical or personal information for an emergency care provider
Ex. Allergies

Health Information

Medial History & Medications
Physician's Name
Physician's Phone
List all current medications. If none, enter N/A.*
Does your child have or ever had any of the following:*

Confidentiality Agreement
This is to certify that as a participant of EmpowHERing Minds Academy, I understand that any information (written, verbal, or other) obtained during my time of affiliation must remain confidential. This includes but is not limited to information about participants, patrons, intellectual property, other associate organizations, and any information otherwise marked as or known to be confidential.

I understand that any unauthorized release or carelessness in the handling of this confidential information is considered a breach of responsibility to maintain
confidentiality.

I further understand that any violation to maintain confidentiality could be grounds for immediate dismissal and/or possible liability in any legal action arising from such breach.
Do you accept this confidentiality agreement?*

I agree
Should be Empty: