Girls n Bloom Registration Youth Name* First Last Preferred NameDate* Date Format: MM slash DD slash YYYY Age*Date of Birth* Date Format: MM slash DD slash YYYY Gender*FemaleMaleRace*Ethnicity*Current School*Current Grade*Do you have allergies?*YesNoAllergies*Parent/Guardian #1Name* First Last Relationship to Youth*Address* Address Line 2 City South CarolinaAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific South Carolina ZIP Code Email* Phone Number*Phone NumberEmergency Contact*YesNoParent/Guardian #2Name First Last Relationship to YouthAddress Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Phone NumberPhone NumberEmergency ContactYesNoPlease 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*EmailThis field is for validation purposes and should be left unchanged. Δ