PAYMENT REQUIRED FOR SUBMISSION
Please be advised that a one-time refundable deposit of $50 per participant must be paid before proceeding with this registration. You will be required to attach a screenshot of your proof of payment during the registration process. This deposit will be refunded at the end of the program.
Have you made payment for the program?
WHO IS COMPLETING THIS REGISTRATION FORM.
WE ARE APOLOGIES FOR THE INCONVENIENCE.
For the registration fee, please make an Interac payment of $50 multiplied by the number of intended participants to ladiesinthefamily@gmail.com. Take a screenshot of your payment, as you will need to attach it to the registration form.
PARENT/ GUIDIAN GENERAL INFO.
Parent First & Last Name
Parent Email
Parent Contact Number
Home Address
PARTICIPANT INFORMATION
Paticipant First Name
Which country are you from originally?
Any subject of relevance?
Are there any issues you feel your daughter would benefit from our discussion group (e.g - friendships, mental health, racism ..etc)
Does the participant identify as female?
Participant Last Name
Participant Date of Birth
Any allergies?
If yes, please list. Any prescribled medication(s) Like EpiPen or Inhaler which they carry? Please detail:
Does the participant identify as black?
Add More Program Participants Here!
ADULT PARTICIPANT GENERAL INFO.
Participant First & Last Name
Participant Email
Participant Contact Number
Home Address
Which country are you from originally?
Any subject of relevance?
Are there any issues you feel your daughter would benefit from our discussion group (e.g - friendships, mental health, racism ..etc)
Does the participant identify as female?
Participant Date of Birth
Any allergies?
If yes, please list. Any prescribled medication(s) Like EpiPen or Inhaler which they carry? Please detail:
Does the participant identify as black?
Add More Program Participants Here!
MINOR PARTICIPANT GENERAL INFO.
Participant First & Last Name
Participant Email
Participant Contact Number
Home Address
Which country are you from originally?
Any subject of relevance?
Are there any issues you feel your daughter would benefit from our discussion group (e.g - friendships, mental health, racism ..etc)
Does the participant identify as female?
Participant Date of Birth
Any allergies?
If yes, please list. Any prescribled medication(s) Like EpiPen or Inhaler which they carry? Please detail:
Does the participant identify as black?
Add More Program Participants Here!
Parental Consent (Please Parent enter your full name below)