Registration Form

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 NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Participants Mobile Phone
Please enter a valid phone number.Format: (000) 000-0000.
School Year
School Name
Date of Birth

MonthDayYear
Date
List some of your child's interest/ hobbies
Does your child meet any of the following criteria? (Select all that apply)

Parent Details for Correspondence
Parent/Guardian Name

First NameLast Name
Parent Mobile Phone
Please enter a valid phone number.Format: (000) 000-0000.
Parent email
example@example.com
Emergency Contact 1
Emergency Contact Name

First NameLast Name
Home Phone
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
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.
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.
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.
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.
Parent Signature

Full Semester cost

Sessions will be held on Feb 4, March 18, April 15, May 20, June-TBD

$50.00 Quantity

Cost per session

each individual session will cost $15

$12.00 Quantity

Enter coupon

Total

Credit Card

Cash App Pay

The Bloom Experience Registration Form