Empower Youth Application

Empower Youth Application

AFTER SCHOOL ENRICHMENT
Part I - Personal Information
Applicant Name*

First NameLast Name
Child Age*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Shirt Size (check box)

XSSMLXL
Allergies:
How did you hear about us?*
Part II - Parent/Guardian
Parent Name*

First NameLast Name
Phone Number*
Email Address*
Part III - Education
School Name*
Location*
Current Grade*
Part IV - Additional Children (To enroll in program)
Child Name *

First NameLast Name
Child Age*
Shirt Size (check box)

XSSMLXL
Allergies:
Emergency Contact:
Will you be willing to recommend us?

YesNo
After School Enrichment
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After School Enrichment - Week 1 Register for our after-school program today!! Life Skill Enrichment Program is held M-F from 3 pm - 5pm
$50.00 Quantity



After School Enrichment - Week 2Register for our after-school program today!! Life Skill Enrichment Program is held M-F from 3 pm - 5pm
$50.00 Quantity
Item subtotal:$0.00



After School Enrichment - Week 3Register for our after-school program today!! Life Skill Enrichment Program is held M-F from 3 pm - 5pm
$50.00 Quantity
Item subtotal:$0.00



After School Enrichment - Week 4Register for our after-school program today!! Life Skill Enrichment Program is held M-F from 3 pm - 5pm
$50.00 Quantity
Item subtotal:$0.00



After School Enrichment - Week 5Register for our after-school program today!! Life Skill Enrichment Program is held M-F from 3 pm - 5pm
$50.00 Quantity
Item subtotal:$0.00



After School Enrichment - Week 6Register for our after-school program today!! Life Skill Enrichment Program is held M-F from 3 pm - 5pm
$50.00 Quantity
Item subtotal:$0.00



After School Enrichment - Week 7Register for our after-school program today!! Life Skill Enrichment Program is held M-F from 3 pm - 5pm
$50.00 Quantity
Item subtotal:$0.00



After School Enrichment - Week 8Register for our after-school program today!! Life Skill Enrichment Program is held M-F from 3 pm - 5pm
$50.00 Quantity
Item subtotal:$0.00



Total

$0.00
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