Registration Form

The Bloom Experience 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 Baltimore County Thank you for considering your child to be a part of our community.
Participants Details
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Participants Mobile Phone
Please enter a valid phone number.
School Year
School Name
Date of Birth

MonthDayYear
Date
List some of your child's interest/ hobbies
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 yearMy child identifies as an underrepresented or marginalized student (e.g., based on race, ethnicity, gender identity, disability, etcNone of the above

Parent Details for Correspondence
Parent/Guardian Name

First NameLast Name
Parent Mobile Phone
Please enter a valid phone number.
Parent email
example@example.com
Emergency Contact 1
Emergency Contact Name

First NameLast Name
Home Phone
Home Phone
Please enter a valid phone number.
Email
example@example.com
Relationship to Participant
Registration confirmation
Yes
I give permission for my child to be added to a monitored GroupMe or community group chat for the purpose of receiving updates related to Ladies of Distinction Mentoring, Inc., including programming schedules, volunteer opportunities, community outreach, and event reminders.I understand that the group will be moderated only by the Executive Director and/or a Board Member of Ladies of Distinction Mentoring, Inc.*
YesNo
Yes
Parent Signature

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My Products*

Full Semester cost

Sessions will be held on Feb 4, March 18, April 15, May 20, June-TBD

$50.00 Quantity

Cost per session

each individual session will cost $15

$12.00 Quantity

Enter coupon

Total

$0.00

Credit Card

Cash App Pay

The Bloom Experience Registration Form