EMPOWER GIRLS BUFFALO MAIL IN REGISTRATION FORM
Checks Made Payable to:
Empower Girls Buffalo
PO Box 1011
Buffalo, NY 14220
Workshop you are Registering for: include dates/times__________________________________________________________
Name: ________________________________________________ Age:_______________ Grade: ________________
Address:__________________________________________________________________ School: __________________________________
Contact Info:
Parent Name: _________________________________________ Phone # cell ____________________________work______________
Parent Name: _________________________________________ Phone# cell ______________________________work_____________
Email: ___________________________________________________________________________
Allergies:_________________________________ Health concerns: _______________________________________________________
Emergency Contact Info: _____________________________________________________ Relationship _____________________
Phone # ____________________________________________________________________
Interests/Hobbies: Any other information you would like to share:
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
I do/ I do not give permission for my daughter to be photographed or videotaped by Empower Girls Buffalo for promotion, brochures, website and other relations.
______________________________________________
Parent Signature
Registration is not complete until payment is received in full.
For more information, visit our website at www.empowergirlsbuffalo.com
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