ENROLLMENT APPLICATION

STUDENT INFORMATION

Student's Full Name:

Age:

Date of Birth: / /

Cell Phone: Home Phone:

E-Mail Address:

Occupation:

School:

What program are you interested in?

Any Physical Limitations/Allergies/Medication? [radio* limitation "Yes" "No"]
If YES, please describe in detail:

Why do you want to join our Leadership Academy?

What are your goals, dreams, passions and/or career aspirations:

Please Describe your strengths:

Please describe your weaknesses:

Group classes will usually take place on Saturdays and your private one-one one session weekly on a day of your choosing for one hour. Please give us 3 choices below for best times and days for you and we will do our best to accommodate.

Choice 1: Day of the Week: Time: :  AM PM

Choice 2: Day of the Week: Time: :  AM PM

Choice 3: Day of the Week: Time: :  AM PM

When can you start (required)?

EMERGENCY CONTACT INFO

Emergency Contact's Full Name:

Cell Phone: Work phone:

Fax: E-mail address:

Street Address:
City: State: Zip:

Please UPLOAD your essay now, if it is complete and ready (.doc, .docx, or .pdf files supported):

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