be a part of our story

We are so excited for our 2018 Mother's Day Retreat!  Please complete the form below with your parent or guardian to let us know you are joining us:

Are you enrolled with empowerHER? if not, please use the link "ENROLL A GIRL" on the left to enroll before registering. *
Tell us about yourself: *
Attendee Name *
Attendee Name
Date of Birth
Date of Birth
Attendee Cell Phone *
Attendee Cell Phone
Attendee Address *
Attendee Address
Parent/Guardian Name *
Parent/Guardian Name
Parent/Guardian Cell Phone *
Parent/Guardian Cell Phone
Parent /Guardian Address (if different from attendee)
Parent /Guardian Address (if different from attendee)
I hereby grant permission for empowerHER to use the above named minor’s images on the empowerHER website or other official publications.  *
Date *