be a part of our story

We are so excited for our January 2018 Pre-Teen "REAL TALK"!  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. *
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 *