Contact Information

Nickname
Date of Birth*

*When entering date of birth please do not add extra 0's and use a two-digit year, for example,  4/2/75.

Country*
Email*
Confirm Email*
Phone*
Church*

Currently Empower is only offered in English, however, as we plan for the future, we would like to know if you have another preferred language.  If you prefer a language other than English, please enter it below.

Preferred Language

Class Location

If you do not live within 60 miles of any of the Empower sites listed above, you may choose Livestream for your location according to your time zone.  If you are an international student in a timezone outside of what is listed, please contact us at info@empowerww.org.

Acknowledgement

I acknowledge that the Empower One program is a full year commitment, and that no refunds will be given. 

 

I understand that Empower classes in the Manhattan location will be live streamed, and I give permission to appear on camera as a class participant.

 

*Due to Covid-19 and in accordance with local government restrictions, Empower may have to hold classes online instead of in-person.  In the event of such local restrictions, students are expected to continue classes online with no issued refunds.

Signature*

Empower One Registration

Quantity
Price
Total
Regular Registration

Full price registration 7/2/20 - 8/15/20. Please only use a quantity of 1.

X
$
900.00=
$
0

Early Bird Registration

Early bird registration 4/4/20 - 7/1/20. Please only use a quantity of 1.

X
$
800.00=
$
0

Re-Enrollment Registration

This is for women who have already taken Empower but did not complete and desire to return. Please only use a quantity of 1.

X
$
400.00=
$
0

Final Total:
$
0

Payment Information

Amount*
$
Payment Type
We only accept credit/debit card payments. After you complete this form, select Submit to enter your card details into our secure transaction processor. Your submission will be processed when you finalize your secure payment information.
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