EmpowerHer Registration Form
Our program focuses on helping young girls build resilience, recognize their unique strengths, and gain a sense of belonging. Led by caring mentors who understand the challenges girls face, EmpowerHer creates a safe space for laughter, friendship, and unforgettable memories. Join us on this journey of growth, self-discovery, and sisterhood as we empower the next generation of confident, compassionate leaders.
Participant Information
Full Name of Participant:
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Date of Birth (MM/DD/YYYY):
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Current Grade Level:
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School Attending:
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Child's Race/Ethnicity
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White (Non-Hispanic or Latino)
White (Hispanic or Latino)
Africa-American (Non-Hispanic)
African-American (Hispanic or Latino)
Asian
American Indian/ Native Alaskan
Native Hawaiian
Multiracial
Prefer not to Answer
Parent/Guardian Information
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Parent/Guardian Name(s):
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Phone Number:
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Email:
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Emergency Contact Name and Phone Number:
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Medical & Special Considerations Does your child have any medical conditions, allergies, or special needs we should be aware of?
What Schedule works best for your family, Sessions will be Bi-Weekly?
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Monday Evenings
Parent Input: What Topics Would You Like Us to Cover?(Please check all that apply, or add your own suggestions!)
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Self-Esteem & Confidence
Healthy Friendships & Peer Relationships
Anti-Bullying & Kindness
Personal Hygiene & Self-Care
Emotional Awareness & Coping Skills
Goal Setting & Dream Building
Social Media & Online Safety (age appropriate)
Body Image & Positive Self-Talk
Leadership & Public Speaking
Respecting Differences & Building Community
Other (please specify)
Media Release- Parents must agree*As a mentee of Five Ducks Foundation Inc., I agree to allow my daughter to have pictures/ video taken of her during mentoring sessions.
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Yes
No
I authorize mentors in any emergency situation to administer basic first aide for health or welfare reasons.
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Yes
No
Parent/Guardian Signature & ConsentI give permission for my child to participate in the Five Ducks EmpowerHer Program. I understand this is a mentorship-based program designed to support and empower girls through structured group activities, discussions, and positive role models.
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First Name
Last Name
You will be added to the waitlist; if you spot opens, you will be contacted. Thank you!
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Signature
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Submit
Submit
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