She Can! PA Day Registration
Child Information
Child's First Name
Child's Last Name
School Child Currently Attends
Grade
Please select...
3
4
5
6
Birthdate (mm/dd/yy)
Parent/Guardian Information
Parent/Guardian First Name
Parent/Guardian Last Name
Phone Number
Email Address
Street Address
Town/City
Postal Code
Participant Medical Information
Does your participant have any medical conditions, allergies or medications we should know about?
Yes
No
Specify here:
Emergency Contact First Name:
Who should we call if we can't reach you?
Emergency Contact Last Name:
Emergency Contact Phone Number:
I understand that the She Can! Girls Empowerment Programs are for girls (inclusive of cisgender and transgender girls and nonbinary youth).
I
grant MCRC permission to use photos of my participant on their social media accounts, website, and on promotional materials. (Optional)
I
would like to be added to the She Can! Email Mailing list. (Optional)
Would you like to make a donation to support She Can! Girls Empowerment programs?
No
Yes
Please Note: She Can! programs are always 100% free to attend and a donation is
not required
to participate.
Donation Amount (CAD):
Your credit card will be charged this amount when this form is submitted.
Payment Information
Name on Card
Card Number
MM
YY
Code
Billing Email
reCAPTCHA helps prevent automated form spam.
The submit button will be disabled until you complete the CAPTCHA.
Contact Information