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 Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
Please enter a valid phone number.
Participants Mobile Phone
Please enter a valid phone number.
School Year
Please Select
Grade 6
Year 7
Year 8
Year 9
Year 10
Year 11
Year 12
School Name
Date of Birth
-
Month
-
Day
Year
Date
List some of your child's interest/ hobbies
Does your child meet any of the following criteria? (Select all that apply)
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 year
My child identifies as an underrepresented or marginalized student (e.g., based on race, ethnicity, gender identity, disability, etc
None of the above
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Parent Details for Correspondence
Parent/Guardian Name
First Name
Last Name
Parent Mobile Phone
Please enter a valid phone number.
Parent email
example@example.com
Emergency Contact 1
Emergency Contact Name
First Name
Last Name
Home Phone
Home Phone
Please enter a valid phone number.
Email
example@example.com
Relationship to Participant
Registration confirmation
I understand that my registration is NOT confirmed until I have returned my signed E-Form containing Consent & Payment details.
*
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.
*
Please Select
Yes, I give consent
No, I don't give consent
I give permission for my child to be photographed and/or recorded during Ladies of Distinction events. I understand that these images may be used to promote the organization’s mission through print, digital, and social media platforms.
*
Yes
No
Please note that current event pricing is subject to change. Refunds will only be issued if the organization cancels or postpones the event. We respect your privacy—none of your personal information will be shared.
*
Yes
Parent Signature
My Products
*
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Full Semester cost
Sessions will be held on Feb 4, March 18, April 15, May 20, June-TBD
$
50.00
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Cost per session
each individual session will cost $15
$
12.00
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Payment Methods
Credit Card
Cash App Pay
After submitting the form, you will be redirected to Cash App Pay to complete the payment.
Submit Form
Submit Form
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