Registration Form
Welcome to the Ladies of Distinction Mentoring INC Sign-Up Form! We're excited to provide a safe space, sisterhood, and mentorship for young ladies in Cecil County. Thank you for considering your child to be a part of our community. Sessions will be held September 26, October 24, November 21, and December 12 from 6:00- 7:15pm. Address Neighborhood Community Center 121 Stockton Street Elkton, MD 21922-0157
Participants Details
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
Please enter a valid phone number.
Participants Mobile Phone
Please enter a valid phone number.
School Year
*
Please Select
Grade 4
Grade 5
Grade 6
Year 7
Year 8
Year 9
Year 10
Year 11
Year 12
School Name
Date of Birth
-
Month
-
Day
Year
Date
List some of your child's interest/ hobbies
Does your child meet any of the following criteria? (Select all that apply)
My child is a first-generation college student (neither parent has completed a 4-year college degree)
My household income is less than $48,000 per year
My child identifies as an underrepresented or marginalized student (e.g., based on race, ethnicity, gender identity, disability, etc
None of the above
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Parent Details for Correspondence
Parent/Guardian Name
First Name
Last Name
Parent Mobile Phone
Please enter a valid phone number.
Parent email
example@example.com
Emergency Contact 1
Emergency Contact Name
First Name
Last Name
Home Phone
Home Phone
Please enter a valid phone number.
Email
example@example.com
Relationship to Participant
Emergency Contact 2
Emergency Contact Name
First Name
Last Name
Home Phone
Please enter a valid phone number.
Mobile Phone
Please enter a valid phone number.
Email
example@example.com
Relationship to Participant
Registration confirmation
I understand that my registration is NOT confirmed until I have returned my signed eForm containing Consent & Payment details.
*
Yes
I understand that my registration is NOT confirmed until my payment has been received in full by the due date.
*
Yes
I give permission for my child to be photographed during events and used to promote our events on social media.
*
Yes
NO
Please note that current event pricing is subject to change. Refunds will only be issued if the organization cancels or postpones the event. We respect your privacy—none of your personal information will be shared.
*
Yes
Parent Signature
My Products
*
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Full Semester cost
Sessions will be held on September 26, October 24, November 21, and December 12 from 6:00- 7:15pm
$
50.00
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Cost per session
each individual session will cost $15
$
15.00
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Payment Methods
Credit Card
Cash App Pay
After submitting the form, you will be redirected to Cash App Pay to complete the payment.
Submit Form
Submit Form
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