Special Project - Empowered GirlEmpowered Girl

Parent Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Email *

Girls Name *

First

Last

Age *

What Challenges has she overcome? *

What extracurricular activities does she do? *

What are some of her current struggles or weaknesses she has *

What are some of her strengths? *

Would you be able to meet for a session a weekday Tues-Thursday between 10-3pm for a session approximately 2 hours in length in the Newtown Ct area? *

Would you be willing to sign a full model release so that images and parts of her story can be used on social media, our girls platfrom blog and possibly a published book? *

If not selected would you be interested in investing in an empowerment session at later date if we open up spots? *

Yes, Absolutely I see the positive imapct this can have on my daughter
Maybe, I would have to think about it
I'm not sure now is the right time
No, its not something that fits my budget

Why do you want her to be a part of this experience? *

Anything else we should know or you want to add?

Empowered Girl

Empowered Girl Special Project

Application form

​Empowered Girl Special Project

​Application form

Empowered Girl Special Project

Application form