EMA Intent To Enroll Pre-Registration

Thank you for your interest in EmpowHERing Minds Academy. You are completing the pre-registration for program year 2025-2026.

Enrollment will open officially in June 2025. At that time, you will be notified to complete registration and payment of enrollment fee.

Personal Information
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
E-mail*
Tshirt Size*

Parent/Guardian Information
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Address (if different than member)

Street Address

Street Address Line 2

CityState

Zip Code
E-mail*
example@example.com

Education
School name*
Current Grade*
Year
Graduation Year*
Year
What are you hoping to gain from the EmpowHERing Minds Academy?*

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