Course Registration

Registration Form

Applicant Name

First Last

School and Grade

Home Address

Street Address Address Line 2 City State ZIP Code

Phone

Parent/Guardian Name

First Last

Home Address

Street Address Address Line 2 City State ZIP Code

Phone

Parent/Guardian Approves Registration?

Yes

REGISTRATION IS FOR WHICH COURSE?

Leadership Institute – Grades 7 & 8 ($90.00)

Leadership Academy – Grades 9 & 10 ($175.00)

Total

Payment Method

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name