Initiate Registration Form

Butterfly Convergence for Black Girls
& the Women Who Love Them

Registration 2024

JULY 25 & 26, 2024

Location:
NEIU Carruthers Center for Inner City Studies (CCICS)
700 E Oakwood Blvd, Chicago, IL 60653

Child's Name*

First NameLast Name

Child's Email

example@example.com

Child's Phone Number

Birth Date*

MonthDayYear

Age*

Middle/High School Name*

Additional Child's Name

First NameLast Name

Birth Date*

MonthDayYear

Age*

Middle/High School Name

Child's Email

example@example.com

Parent's Name*

First NameMiddle NameLast Name

Parent Phone Number*

Parent Email

example@example.com

Estimate Family Yearly Income*

Present Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Emergency Contact 1*

First NameLast Name

Relationship*

ex. Father, Mother, etc.

Phone # of Contact 1 In Case Of Emergency*

Please enter a valid phone number.

Email Of Person 1 To Contact In Case Of Emergency

example@example.com

Emergency Contact 2*

First NameLast Name

Relationship*

ex. Father, Mother, etc.

Phone Number Of Person 2 To Contact In Case Of Emergency*

Please enter a valid phone number.

Email Of Person 2 To Contact In Case Of Emergency

example@example.com

Does she have any food allergies?*

YESNO

If Yes, Please explain.

Is she taking any medications?

YESNO

If Yes, Please explain.

Are there other conditions we should be aware of?

Child's Physician Name

Name of Insurance Co.

Policy #

What would you and/or her like to gain from participating in this experience?*

How did you hear about the conference*

Skills/Talents

I agree that this application and any other documents to be delivered in connection herewith may be electronically signed, and that any electronic signatures appearing on this application, or such other documents are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility. By typing your name below, you agree that this application, along with any other documents connected with it, may be electronically signed. You acknowledge that the electronic signature, consisting of your typed name, will be treated as equivalent to your handwritten signature for all purposes related to the validity, enforceability, and admissibility of this application and any associated documents.*

YES

Parent/Guardian*

Today's Date*

Date

REGISTRATION PACKAGES*

BUTTERFLY SOLO PASSEmpowHER with an individual ticket to the Butterfly Convergence. This ticket grants one Black girl aged 13-19, mama, auntie or mentor access to all sessions, workshops, and activities throughout the event. Join us for an inspirational and transformative experience tailored to uplift and celebrate you!

$99.99 Quantity
Item subtotal:$0.00

BUTTERFLY BUDDY PASSBring a friend or sibling along! This additional child ticket allows another Black girl aged 13-19 to participate in the Butterfly Convergence alongside the main ticket holder. Share the journey of empowerment, growth, and celebration together.

$94.99 Quantity

BUTTERFLY DUO PASSExperience the Butterfly Convergence together with an Adult & Child Ticket. This ticket includes entry for one adult (mother, auntie, mentor) and one Black girl aged 13-19. Engage in empowering conversations, workshops, and cultural activities designed to strengthen bonds and foster mutual growth.

$184.99 Quantity

BUTTERFLY SPONSOR PASS (Cover Her Conference Registration) Product Image

BUTTERFLY SPONSOR PASS (Cover Her Conference Registration) Support a girl's journey of empowerment by becoming a sponsor today! Your contribution can make a meaningful difference in the life of a young lady. Whether it's covering conference fees or educational materials, your sponsorship helps pave the way for her success. Become a catalyst for positive change. Together, we can empower the next generation of strong, confident, and resilient women. Donations are available for tax write off.

$99.99 Quantity

Enter coupon

Total

$0.00

Payment Methods

Debit or Credit Card

Please click one of the PayPal options to complete payment and submit the form.

Registration Form

Child's Information

Parent/Caregiver Information

Emergency Contact Information

Medical Information

YAAAS! RESERVE YOUR SPOT NOW.