Survivor Empowerment Program

Fill the form below to register for the class.

Class schedule: October 12 – November 16.

Class holds every Saturday for three hours (10:00 a.m. – 1:00 p.m.). If you have any questions completing this form, please, contact Bukola Oriola at info@enitan.org or call 7635164359

Name

Date of Birth (must be age 24 or under )

If under age 18, please provide parent or guardian contact information below: Parent or Guardian Name and Phone Number:

Address

Phone

How can we best reach you?(required)

Call

Text

Do you have transportation to attend the classes?(required)

Yes

If not, would you like us to provide you with transportation to get you to class? (required)

Yes

This class will be held once a week, every Saturday from 10:00 a.m. until 1:00 p.m. for six weeks. Are you able to come to all six classes? (required)

Yes

If not, what may keep you from successfully attending all the classes?

Do you have any kind of emergency needs such as food, clothing, healthcare, housing, etc. ? Please explain.