Program of Interest
*
Student's Name
*
First Name
Last Name
Student's Age
*
Student's Grade (entering grade in Fall 2025)
*
Student's School Name
*
Student’s Allergies to medicines/food (include if airborne, etc.)
*
Reaction to Allergen
*
Parent / Guardian's Name
*
First Name
Last Name
Parent / Guardian's Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Parent / Guardian's Phone
*
(###)
###
####
Parent / Guardian's Email
*
Emergency Contact's Name
*
First Name
Last Name
Emergency Contact's Relationship to Student
*
Emergency Contact's Phone
*
(###)
###
####
Emergency Contact's Email
*
Which Roots & Wings OR EmpowerED workshop session are you interested in?
*
Note: Both programs follow the same schedule. If you are interested in signing up for Beyond the Binary, select "N/A"
Which Beyond the Binary workshop sessions are you interested in?
*
If you are interested in signing up for Roots & Wings or EmpowerED, select "N/A"
How did you hear about us?
Word of mouth
Social Media
Newsletter
Community News
