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Annual Membership Fee

Level One: 13 to 17

Full Name

Phone Number

Emergency Contact

Do you have allergies?

Yes

If Yes please specify or if No enter NA

Do you take medication?

Yes

If Yes please specify or if No enter NA

Do you have any medical conditions?

Yes

If Yes please specify or if No enter NA

Price

Comments

Agree to being photographed or videoed

Check box if you agree with below agreements:

I am responsible for making sure my child/mentee/student(s) reach home safely. No person working with Herunivercity Inc. is responsible for any transportation.

Thank you!

Form submission is complete. Please utilize the QR code displayed below to finalize your payment transaction. Your request will be processed once payment is verified.

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Level Two: 18 and Above

Full Name

Phone Number

Emergency Contact

Do you have allergies?

Yes

If Yes please specify or if No enter NA

Do you take medication?

Yes

If Yes please specify or if No enter NA

Do you have any medical conditions?

Yes

If Yes please specify or if No enter NA

Price

Comments

Agree to being photographed or videoed

Check box if you agree with below agreements:

I am responsible for making sure my child/mentee/student(s) reach home safely. No person working with Herunivercity Inc. is responsible for any transportation.

Thank you!

Form submission is complete. Please utilize the QR code displayed below to finalize your payment transaction. Your request will be processed once payment is verified.

Error

Bad respond

Donate a Membership Today

(Membership includes 20 hours of mentorship + a t-shirt.)

Herunivercity Inc.

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P.O. Box 22274, Brooklyn, NY 11202

Phone: (929) 373-7130 | Copyright ©. Herunivercity Inc. All rights reserved.

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