Child’s Name
First Name
Last Name
Age
example@example.com
Grade
Date of Birth
Parent Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Does your child have any allergies, chronic illness, or medical conditions? If yes, please describe.
I hereby give my approval for my child's participation in any and all activities prepared by BrokeCan’s Empowerment Day.
Yes
No
A $25 refundable fee is required to reserve your child’s spot. This fee will be returned to you if your child attends the event. However, if your child does not attend, the fee will not be refunded. Do you agree to these terms?
Which Session Will Your Child Attend?
9a-12p
1p-4p
Submit
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