Girls LEAD Program

Girls LEAD Program

Register for CHAMP’s Girls LEAD Summer Empowerment Experience for moms and daughters ages 8–12. Space is limited. Field trips, food, drinks, and snacks are provided through sponsor support.
Parent / Guardian Information
Mother/ Guardian Full Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Home Adress

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Contact Method

Emergency Contact
Emergency Contact Full Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Daughter

Consent / Disclaimer

Photo & Media Release Disclaimer
By registering for Girls LEAD, you understand that photos and videos
may be taken during program activities for CHAMP marketing, social
media, website, and promotional purposes.
Do you give CHAMP permission to photograph/video your daughter and use those images for program and promotional purposes?
Girls LEAD includes educational field trips. All field trips are
covered by sponsor support, and food, drinks, and snacks will be
provided throughout the program.
Do you give permission for your daughter to participate in Girls LEAD field trips?
Participation Acknowledgment
Parent/Guardian Signature
Date

MonthDayYear
Date
Should be Empty:

Parent / Guardian Information