Bloom and brunch Registration form

Bloom & Brunch Registration

Thank you for your interest in Bloom & Brunch hosted by Next level Ascent Inc. This free event is designed for girls ages 10-13 to build confidence, learn self care, enjoy brunch, and connect with other girls in a positive and empowering environment. Registration is required and space is limited to 25 participants.
Participant Information

Please provide information about the girl attending Bloom and brunch
Youth First Name
Enter the Child's first name
Youth Last Name
Enter the Childs last name
Youth Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearMM/DD/YYYY
Youth Age
Enter Childs Age
Youth Grade
Select childs Grade
School Name
Enter Participants school name

Parent/ Guardian Information

Please provide the information for the parent or legal guardian responsible for the participant.
Parent/Guardian Full Name

First NameLast Name
Relationship to Participant
Example:Mother,Father, Grandparent,Guaridian
Parent/Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Email Address
example@example.com
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact & Medical Information

Please provide emergency contact and important medical information so we can ensure your child's safety during the event.
Emergency contact Full Name

First NameLast Name
Relationship to Participant
Example:Aunt,Grandmother,Family Friend
Emergency ContactPhone Number
Please enter a valid phone number.Format: (000) 000-0000.
Does Your Child have any allergies
If Yes, Please list all Allergies
Food,medication,insect,environmental,etc
Does your child have any medical Conditions we should know about?
Asthma,diabetes,seizures,anxiety, etc
Does your child have any dietary restrictions or food allergies?
Example: Peanut allergy, dairy-free vegetarian, gluten-free, etc.

Parent Consent & Acknowledgement

Please review the information below before signing. Your electronic signature confirms that the information you provided is accurate and that you give permission for your child to participate in Bloom and brunch.
By Signing below, I certify that the information provided on this registration form is true and accurate. I give permission for my child to participate in Bloom & Brunch hosted by Next Level AScent Inc. I understand this is a community event, and I agree to follow all event guidelines.
Type a question
Parent/Guardian Signature
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Bloom & Brunch Registration