ENROLLMENT APPLICATION

STUDENT INFORMATION

Student's Full Name:

Age:

Date of Birth: / /

Cell Phone: Home Phone:

E-Mail Address:

Occupation:

Current Grade (if applicable): Current GPA (if applicable): .

School:

Religious Preference:

What program are you interested in?

Any Physical Limitations/Allergies/Medication?  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)?

PARENT / GUARDIAN INFORMATION

MOTHER'S INFORMATION

Mother's Full Name: Occupation:

Cell Phone: Work Phone:

Fax: Home Phone:

E-mail address:

Street Address:
City: State: Zip:

Mailing Address (if different from above):
Street Address:
City: State: Zip:

Mother is:  Single Married Divorced Widow

Mother is:  Bio Mother Step or Adoptive Mother Foster

FATHER'S INFORMATION

Father's Full Name: Occupation:

Cell Phone: Work Phone:

Fax: Home Phone:

E-mail address:

Street Address:
City: State: Zip:

Mailing Address (if different from above):
Street Address:
City: State: Zip:

Father is:  Single Married Divorced Widow

Father is:  Bio Father Step or Adoptive Father Foster

If remarried, step-mother’s name:
Years married:

Is student legally adopted by Stepmother?  Yes No

EMERGENCY CONTACT INFO

Emergency Contact's Full Name:

Cell Phone: Work phone:

Fax: E-mail address:

Street Address:
City: State: Zip:

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