PROGRAM APPLICATION

Thank you for your interest in Becoming the Lady Within. Our 12 month program empowers girls and young women to discover their voice, embrace their worth, and grow in confidence, dignity, life skills, and grace from the inside out. Complete the application below to begin your journey toward becoming a confident, purpose filled young woman.

APPLICATION INFORMATION

First Name*

Last Name*

Preferred Name

Birthday*

Month

Day

Year

Age*

Grade Level or School Status*

Middle School

High School

College

Working

Not currently in school

Other

School Name (If Applicable):

Phone*

Email Address*

Multi-line address

Country/Region*

Address*

City*

Zip / Postal code*

PARENT/GUARDIAN INFORMATION

Required for participants under age 18.

Parent/Guardian Name

Relationship to Applicant

Parent/Guardian Phone Number

Parent/Guardian Email Address

EMERGENCY CONTACT INFORMATION

Emergency Contact Name*

Emergency Contact Phone Number*

Relationship to Applicant*

TRANSPORTATION INFORMATION

How did you hear about our program? Select all that apply.*

Parent/Guardian

Drives Self

Public Transportation

Rides with Approved Adult

Other

Please provide the name of the person authorized to pick up the participant.

Authorized Person's Phone Number

PROGRAM INTEREST

What motivated you to apply for Becoming the Lady Within?*

How did you hear about our program?*

Parent/Guardian

A Friend

School Referral

Church/Community Referral

Social Media

Other

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