Register for 2021-22 Seminars

Select the program *

Step Up (9th Grade Girls)

Big Ideas (10th - 12th Grade Girls)

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Participant Phone

(###)

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Parent/Guardian Name *

First Name

Last Name

Parent/Guardian Phone *

(###)

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Photo & Medical Release *

By entering my name, I understand that I am signing as a parent or legal guardian of the applicant. In signing, I authorize Pivot Leadership Program staff to seek medical assistance for my daughter, should the need arise. In addition, I authorize any photography that includes my daughter to be used for the purpose of promoting Pivot. I understand that such photography remains property of Pivot Leadership Program.

First Name

Last Name

As parent/guardian, I hereby release Pivot, its officers, directors, employees, and volunteers from any liability for any mishap or injury. *

I agree