Online Registration

Live Resilient Enrichment Program

Empowering High School Girls...Live Resilient, because Resilience Lives in You!
Parent/Guardian First & Last Name *
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Student Information *

First NameLast Name
Birth Date*

MonthDayYear
Date
School Name *
Grade *
Single-parent household?*

YesNo
First-generation college student?*

YesNo
Student Email
example@example.com
Student Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Shirt Size
Emergency Contact Information

(Name, phone number, and relationship
Description of parent/student expectations (please include parent & student goals)
Short Essay (Min. 50 words) Tell us about yourself, what resilience means to you, and how you've overcome adversity.

Cancelof
"I understand that, if selected, I am committing to attend and participate in all program activities."*

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Live Resilient Enrichment Program