GLOW SHINE Academy Registration Form for GLOW Series Question Title * 1. What is your name? (Required.) Question Title * 2. Please select the age group that applies to you 14-17 18-20 21 and above Question Title * 3. What is your street address? Question Title * 4. Zip Code (Required.) Question Title * 5. Parent's First Name (Required.) Question Title * 6. Parent's Last Name (Required.) Question Title * 7. Parent's Cell Phone number (in case of emergency) (Required.) Question Title * 8. What is your gender? Female Male Other (specify) Question Title * 9. What is your race or ethnicity? Asian Black or African American Hispanic or Latino Middle Eastern or North African Multiracial or Multiethnic Native American or Alaska Native Native Hawaiian or other Pacific Islander White Another race or ethnicity, please describe below Self-describe below: Question Title * 10. Which tracks are you interested in? Select your top 2 (Required.) DANCE - Starting July 14th 10:00 AM - 1:00 PM and 15th 12:00 PM - 3:00 PM at The Underground (3225 N Dries Ln, Peoria, IL 61604) Physical Activities Trades Workforce Development Entrepreneurship, Innovation and Startup Weight Training & Fitness Question Title * 11. What's your Cellphone Number (Required.) Question Title * 12. What's your CASHAPP Handle (Required.) Question Title * 13. Do you have transportation to our series locations? (Required.) Yes No Question Title * 14. Is there violence in your neighborhood? Or two to three blocks in any direction? (Required.) Yes No Done
