Registration Please fill out the details below to register for InfluenceHER by xx/xx/xx. 1. Name of school*2. School address* Street Address City State / Province / Region ZIP / Postal Code Name of Principal* Dr.MissMr.Mrs.Ms.Prof.Rev. Prefix First Last Principal's Email* Name of school representative (who will serve as InfluenceHER coordinator)* Dr.MissMr.Mrs.Ms.Prof.Rev. Prefix First Last School Representative Email* Name of student representative (if applicable) First Last Student Representative Email (if applicable) 3. Total number of students in your school*4. Number of 11th and 12th grade students that will participate in InfluenceHER*5. Students will join as:*part of a clubas part of a course requirementas an extracurricular activityas a mandatory seminarindependentlyPromotional CodePayment MethodPay online belowPay via checkIf you would like to pay by check, please contact Eliana Sohn Cohen (sohne@ou.org) to coordinate.InfluenceHER registration* Price: $375.00 InfluenceHER registration* Price: $275.00 InfluenceHER registration* Price: $200.00 InfluenceHER registration* Price: $150.00 InfluenceHER registration* Price: $0.00 Coupon Total $0.00 Credit Card American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20232024202520262027202820292030203120322033203420352036203720382039204020412042 Expiration Date Security Code Cardholder Name
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