EmpowerED Program Pre Registration Form

Pre Registration Form

Educate. Empower. Elevate.
Youth's Information
Youth's Name*

First NameLast Name
Birth Date:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Gender

FemaleMaleNon BinaryPrefer Not to Say
Grade (as of next school year)*
Name of School*
County
T-Shirt Size

SmallMediumLargeX-LargeXX-Large
Parent/Guardian Information
Name*

First NameLast Name
Cell Number*

Area CodePhone Number
E-mail*
Does the child have any allergies, chronic illness, or medical conditions? If yes, please describe.*
Class Selection*

September 27, 2025October 18, 2025November 15, 2025
Program Committment & Agreement

By submitting this pre-registration form, I commit to supporting my youth’s full participation in the EmpowerED Pathways Program and ensuring their attendance and engagement throughout the program. I understand that full registration may require additional paperwork.
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
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