S.H.E.E. Foundation Participant/Fellow Registration Form

S.H.E.E. Foundation Participant/Fellow Registration Form
General Information
Participant Name

First NameMiddle NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Birth Date

MonthDayYear
Ethnicity
Gender
Entry Year

Residence Information
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Address (if different from above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact Information
Primary Emergency | Contact Name

First NameLast Name
Primary Emergency | Phone Number
Please enter a valid phone number.
Primary Emergency | What is your relationship with this person?
Secondary Emergency | Contact Name

First NameLast Name
Secondary Emergency | Phone Number
Please enter a valid phone number.
Secondary Emergency | What is your relationship with this person?

Please write a statement below explaining why you would like to be chosen as a S.H.E.E. Foundation participant.
Please write a statement below explaining what S.H.E.E. Foundation program(s) you would like to be enrolled in and why. (Life Skills Development, Trauma Informed Care and Principles, Coaching Services - Talk Session)
Enrollment Agreement
By submitting this form, the undersigned hereby consents to participate in one or more programs under the guidance of the S.H.E.E. Foundation and/or its affiliates and contracted providers.

The undersigned hereby assumes all risk of injury or harm as a result of any activities associated with the S.H.E.E. Foundation and/or its affiliates and contracted providers and agrees to release, indemnify, defend, and forever discharge the releasee from all liability, claims, demands, damages, costs, expenses, and causes of action due to death, injury, loss, or damage to the undersigned.

The undersigned hereby consents to a photographer to use and/or publish photographs in S.H.E.E. Foundation advertisements which includes and is not limited to social media platforms without monetary compensation.

This Participant Registration Form can be withdrawn within 36 hours of a signature by sending an email to the S.H.E.E. Foundation at info@thesheefoundation.org

The undersigned hereby consents to pay a $10 non-refundable one-time enrollment fee at the time of orientation (unless waived by SHEE Foundation) submission by credit card or cash.

The undersigned hereby confirms she is at least 18 years old.
Signature

Clear
Should be Empty:

S.H.E.E. Foundation Participant/Fellow Registration Form

General Information

Residence Information

Emergency Contact Information

Enrollment Agreement