Girls n Bloom Registration

Youth Name*
First Last
Preferred Name
Date*
MM slash DD slash YYYY
Age*
Date of Birth*
MM slash DD slash YYYY
Gender*
- Female
- Male
Race*
Ethnicity*
Current School*
Current Grade*
Do you have allergies?*
- Yes
- No
Allergies*
Parent/Guardian #1
Name*
First Last
Relationship to Youth*
Address*
Address Line 2 City South Carolina ZIP Code
Email*
Phone Number*
Phone Number
Emergency Contact*
- Yes
- No
Parent/Guardian #2
Name
First Last
Relationship to Youth
Address
Address Line 2 City State ZIP Code
Email
Phone Number
Phone Number
Emergency Contact
- Yes
- No
Please answer these questions.
1. Why do you want to participate in the Girls N Bloom Program?*
2. By participating at 100% effort in each Girls N Bloom event, what do you expect to gain?*
3. What activities do you want to do while participating in Girls N Bloom?*
4. What are your favorite things to do?*
5. What is something that makes your family special?*
6. What 5 words best describe you?*
7. What would you like to be when you grow up?*
8. What's your favorite food?*
Parents will be interviewed by BLOOM UPSTATE INC. facilitators before being accepted into the program.
Consent*
I want to be involved with the GIRLS N BLOOM program. I understand the information in this application will remain confidencial and be used only by GIRLS N BLOOM facilitators. I understand this is a voluntary program and that GIRLS N BLOOM events must be a top priority for me during the program. I have permission from my parent(s)/guadian(s) to participate in BLOOM UPSTATE Program.
Initial*
Comments
This field is for validation purposes and should be left unchanged.

Girls N Bloom Registration

Girls n Bloom Registration

Parent/Guardian #1

Parent/Guardian #2

Please answer these questions.

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