Child's Name (one child per form please)
*
First Name
Last Name
Grade as of September 2024
*
5th
6th
7th
Parent's Name
*
First Name
Last Name
Parent's Email
*
example@example.com
Parent's Cell Phone
*
Please enter a valid phone number.
Emergency Contact Information
*
Name
*
Relationship to child
*
Best number to call in an emergency
Please list the name, phone number and relationship, of those allowed to pick up your child.
Registration
*
prev
next
( X )
EmpowerHER
Wednesdays, July 10th - August 14th, 5:00 - 6:00 pm
$
Free
Submit
Should be Empty: