EmPower Her Academy Application "*" indicates required fields Step 1 of 3 33% Participant InformationParticipant Name* First Last Date of Birth* MM slash DD slash YYYY Grade Level*School Name*Home Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Participant Email* Participant Phone*Parent/Guardian InformationParent/Guardian Name* First Last Relationship to Participant*Phone*Email* Emergency Contact Name (if different from above)*Emergency Contact Phone Number* Program Interest & CommitmentWhy are you interested in participating in the EmPower Her Academy of Excellence?*Which core area(s) are you most interested in? (Check all that apply)* Business Etiquette Civics Life Skills How did you hear about the program?*Are you willing to commit to attending all workshops and events?* Yes No (please explain) Explain:*Medical & Special Needs InformationDoes the participant have any medical conditions, allergies, or special needs we should be aware of?* No Yes (please specify) Specify:*Does the participant require any accommodations to participate fully?* No Yes (please specify) Specify:* Parent/Guardian ConsentConsent* I, (Parent/Guardian Name), give permission for my child, (Participant Name), to participate in the EmPower Her Academy of Excellence. I understand that this program is designed to equip young women with essential skills and knowledge for personal and professional success. I also acknowledge that my child must adhere to program expectations and guidelines.I consent to the use of my child's name, image, or likeness in photos/videos for program promotional purposes.* Yes No Today's Date* MM slash DD slash YYYY Participant AgreementConsent* I, (Participant Name), understand that participation in the EmPower Her Academy of Excellence requires commitment, respect, and active engagement. I agree to attend workshops, participate fully, and follow program guidelines.Today's Date* MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged.
