Course Registration Form

Girls Empowerment & Leadership Class Registration Form

Fill out the form carefully for registration
Student Name

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Phone Number
Please enter a valid phone number.
Mothers Name

First NameLast Name
E-mail
example@example.com
Phone Number
Please enter a valid phone number.
Work Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Fathers Name

First NameLast Name
E-mail
example@example.com
Phone Number
Please enter a valid phone number.
Work Number
Address (If Different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What school does your child attend?
Grade
Class
Does your child participate in any sports, dance, or other activities?
Does your child have any allergies?

YesNo
If yes,whay are they allergic to?
Briefly describe your child's personality
What are you hoping you child will learn in this class?
Should be Empty:

Girls Empowerment & Leadership Class Registration Form