JLP's Girls' Empowerment

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Sunday, November 5, 2023

10:00 AM - 1:00 PM

Locust Grove Estate

2683 South Rd, Poughkeepsie, NY 12601

Please note: This registration form will take about 5 minutes to complete. All sections are needed in order to submit and register. At the conclusion of the event, IDs will need to match Parent/Guardian or Custodial Release as indicated on this form. Please email questions to: jlpgirlsempowerment@gmail.com

We look forward to seeing you on November 5th!

Email *

First Name *

Last Name *

Birthdate *

YYYY

Home Address (street, city, state and zip) *

Home Phone *

School/Program you attend *

Grade *

Medical History *

Please indicate if you have any:

Allergies

Dietary Restrictions

Medications

Health Concerns

None of the above

Other:

Please explain any indications/needs identified above.

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