Grief Support For Teens & Children

Youth age 14+ may enroll themselves at Empower. Is the person completing this form 14 years of age or older?*

YES - I am 14 years old or older!

No - form to be filled in by Guardian

Which Region do you live in?*

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Youth

Youth's First Name*

Youth's Last Name*

Youth's Pronouns*

Youth's Date of Birth*

Youth's Grade In School*

Youth's Street Address*

Youth's City*

Youth's State*

Youth's County*

Youth's Zip Code*

Youth's Email*

By entering the address below, Empower will share important event and program information via email. Please enter Guardian's Email if youth does not have a personal email address.

Youth's Cell Phone*

By entering the cell phone below, Empower will share important event and program information via text message. The youth may unsubscribe anytime. Please enter Guardian's Phone if the youth does not have a cell number.

Youth's Ethnicity*

Asian/Pacific Islander

Native American or American Indian

Black or African American

Hispanic or Latino

White

Other

Prefer not to answer

How did you hear about Empower?*

If you chose "Other" please explain*

Which type of loss did you experience?*

Mentor Preference*

Which Mentor do you prefer? Our Program Coordinator will reach out to you based on your preference:)

If you would, please share how and when your parent(s) passed away:*

We are so very sorry for the loss of your parent. We are glad you found us and are now a part of the Empower family.

Guardian Full Name*

If you are not the Guardian, please be sure to notify them ahead of time.

First Name Last Name

Guardian Street Address*

Guardian City*

Guardian State/Country*

Guardian Zip*

Guardian Email*

Guardian Phone*

Guardian's Relationship to youth enrolling in Empower*

Referral Full Name

If you are not the Guardian, please share your name below. If you are the Guardian or Youth, simply put N/A

Referral's Relationship to youth enrolling

Referral Email

Referral Phone

Is the Guardian aware that you are completing this enrollment?*

Yes

No (If not please inform guardian that we will be contacting them to complete the process)

Media Release*

Empower everywhere includes various fun + interactive workshops, activities and outings in which photos may be taken and/or the participant may choose to take photos on her own. We kindly request permission to use the above-named images in Empower collateral to include website or other official publications. For all virtual events, the content may be shared with enrolled girls who may have missed the event, post-production. If permission to share your image is not granted, the camera should remain off during the virtual event.

I give my full permission to Empower and corporate partners to use any photographs, videotapes, or other recordings of me that are created during this event. I understand that the liability waiver and media release may be stored electronically and agree that a copy is authentic and admissible as evidence in any future dispute or proceeding. Permission may be revoked at any time.

We would love to learn more! Please feel free to share any additional information about yourself with Empower below:*

We are proud to welcome you to the Empower family!

We are so glad you found us.

Youth