EmpowerMEnt Sign In Sheet

Empower Who?

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* 1. Date of Event

Date / Time

Date

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* 2. Name of event

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* 3. Contact

Name

Agency

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 4. Do we have permission to use your pictures

Yes

No

I am under 18

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Regional Map

Regional Map

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* 5. What region are you from?( Look at map above)