Web Site Refined & Empowered Outreach Program Registration Form Participant Information Full Name * Date of Birth Age Preferred Name/Nickname Address City/State/ZIP - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Phone Number Email Address Parent/Guardian Information (Required if participant is under 18) Parent/Guardian Name Relationship to Participant Parent Phone Number Parent Email Address Emergency Contact Name Emergency Contact Phone Number Education Information Current School/College Grade Level or Year Career Goals / Future Aspirations Current Employment Status (Optional) Program Interest Questions Why are you interested in the program? Which focus areas interest you most? Self-Care & Wellness Mindset & Confidence Money Management Banking & Financial Literacy Manners & Professional Etiquette Healthy Relationships What do you hope to gain from the program? Availability Are you able to attend monthly sessions? Yes No Preferred Contact Method Name Email Phone Call Medical / Safety Information (Optional but recommended) Allergies or Medical Conditions Accessibility Accommodations Needed? Authorized Pickup Person (if applicable) Media Release I give permission for photos/videos taken during program activities to be used for promotional and educational purposes. * Consent & Agreement / Participant Agreement I give permission for my child to participate in the Refined & Empowered Outreach Program. Upload Digital Signature Date
