Teen Empowerment Summer Camp Registration – Better With Betsy

Teen's Name*
First Last
Teen's Place of Birth*
Teen's Date of Birth*
MM slash DD slash YYYY
Languages Spoken*
- English
- Spanish
- Other
School Name*
Grade?*
Teen's Cell Phone Number (if applicable)
Teen's Email (if applicable)
Address*
Street Address Address Line 2 City Florida ZIP / Postal Code United States
Mom's Name*
First Last
Mom's Phone Number*
Mom's Email*
Dad's Name*
First Last
Dad's Phone Number*
Dad's Email*
Parents' Relationship Status*
The teen lives with the following family members: (include relationship and age)*
What made you register for our Teen Empowerment Summer Camp?*
What do you hope to get out of this amazing week?*
Is there a topic you would like for us to cover in order to specifically benefit your teen? Please explain.
How did you hear about our Empowerment Summer Camp?
Coupon Code
Billing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Service*
Price:
Service*
Price:
Total
$0.00
Credit Card

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name