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JOIN OUR PROGRAM

BECOME A QUEEN

Thank you for your interest in signing up your child to be a part of the Perfectly Imperfect Girls non-profit organization. To be eligible to join our program, your child must be female and between the ages 12-18. Please fill out the form below to begin the enrollment. For any questions, refer to our Contact Us page or call us at (336) 920-9646.

GENERAL INFORMATION OF CHILD

HOME ADDRESS

EDUCATION

MEDICAL HISTORY

Does your child have any medical conditions or allergies? Please list below any conditions in order for us to accommodate your child's needs.

Please list any medications taken for any of the conditions listed above.

PARENT/GUARDIAN INFORMATION

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Are there any additional information you would like for us to know about your child?

I verify that the information I am submitting is accurate and truthful to the best of my knowledge. By signing and clicking 'submit' below, I attest to the truthfulness of all information listed on this application and permit my child to participate in Perfectly Imperfect Girl's program.

THANK YOU FOR YOUR SUBMISSION.