Lady EMINENCE Participant Interest Form
We appreciate your interest in Lady EMINENCE. Please fill out the form as thoroughly as possible.
Date
-
Month
-
Day
Year
Date
Youth's Information
Name
First Name
Last Name
Name of School
Grade Level
Interest/Hobbies
Parent/Guardian's Information
Parent/Guardian's Name
First Name
Last Name
Relationship to Youth (i.e. mother, father, grandmother, etc.)
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Youth Questionaire
Please answer all of the following questions as completely as possible.
Why do you/your child want to participate in a program such as Lady EMINENCE?
Briefly describe your expectations.
Lady EMINENCE will host enrichment workshops focused on academic achievement, leadership and life skills, career planning and financial literacy, as well as community engagement and relationship building. Is your child able to participate in 80% of the activities provided by Lady EMINENCE. Please explain any scheduling issues.
Submit
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