Polished & Paid Registration Form

Polished & Paid Registration Form
Which Program are you Applying for?
Parent Details:
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail*
example@example.com

Student Details
Student's Full Name

First NameLast Name
Students DOB*

MonthDayYear
Date
What Grade is the Student in?*
Have your child been diagnosed with any of the following?*

Household Information
Are you registering for:*
Number of people in your household*
Do you currently receive any assistance? (Check all that apply)*

SNAPTANFMedicaidHousing AssistanceNone

Program Preference
What workshops or programs are you most interested in? (Check all that apply)*

EntrepreneurshipFinancial LiteracyBeauty-Realted TrainingCareer ReadinessLeadershipMental Health GroupsLife Skills & Goal SettingAll

Availability
What day(s) are you available: (Check all that apply)

MondayTuesdayWednesdayThursdayFriday
What times work best for you?

Please give reference of any two people whom you feel would benefit from P&P:

	Full Name	Address	Contact Number
1
2

How did you hear about us?*
Should be Empty: