Web SiteRefined & Empowered Outreach Program Registration FormParticipant Information Full Name * Date of Birth Age Preferred Name/Nickname Address City/State/ZIP - Select Province/State -AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ====================AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming 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
