Registration

SHE’S GOLD REGISTRATION

Please complete the application and process fee below. If you’d like to apply for financial assistance please email carmen@icementors.org. Registrations will not be complete without submitting program fee.

CLICK PAY NOW to process fee then return to complete form below:

APPLICATION

First Name *

Last Name *

Current Grade *

Zip Code

Age *

Parent/Guardian First Name *

Parent/Guardian Last Name *

Parent Phone Number *

Student Phone Number

Parent Email *

Student Email

What school does she attend? *

How did you hear about the program? *

Please list any food allergies. *

Is your daughter self-motivated and focused? *

Yes

No

Please describe why your child should participate in this leadership program.

I confirm that my daughter is available to commit to the assigned dates and will complete the program to its entirety. I also give permission for her to be photographed for activities and professional use. I agree that ICE Mentors INC and the Eryn Pink Girl Empowerment Program is not liable or responsible for damaged, stolen or loss items while with us. In addition, we are not liable for any body injuries. If an emergency occurs parents will be contacted first for instructions. *

Yes

No

If you are human, leave this field blank.

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