Contact Information

Nickname
Date of Birth*
Country*
State / Province*
Address*
City*
*
*
*
*
*
*
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, with all fees due by November 15, 2019, 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.

Signature*

Empower One Registration

Donation Amount*
  • $225.00

Your first payment of $225.00 will be processed immediately upon submitting your registration.  Your next 3 payments of $225.00 each will be automatically processed for 3 consecutive months beginning one month from today.  Payments will conclude after the grand total of $900 has been met, 4 months from today.  

Payment Information

Amount*
$
Name on Card*
Card Number*

Security Code

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