YWEA Registration
Young Women’s Empowerment Academy
Student's Name *
Parent’s Name *
Phone Number *
Email Address *
Address *
Grade
School
Date of Birth
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Are you a:
Clear selection
T-shirt Size (Women's Size)
Clear selection
Favorite Color
Hobbies, Interests, Skills
Previous Volunteer Experience
What career fields are you interested in?
Would you like a mentor?
Clear selection
How did you hear about our Academy?
Person to contact in case of emergency (Parent/Guardian)
Student’s Relationship to person
Contact phone (Parent/Guardian)
PHOTOGRAPHY/VIDEOGRAPHY WAIVER: I understand that my child may be photographed or recorded on video during the course of class sessions. By acknowledging below I provide consent for their image to be used in either print, electronic, or video form for the promotional purpose of future classes and youth activities. *
Student Signature (Type Name) *
Parent Signature (Type Name) *
Application Date *
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Choose Location *
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