Leadership Academy Enrollment Form

LEADERSHIP ACADEMY ENROLLMENT FORM

Program Selection

Program Name:   Session:

Program Start Date:   Program End Date:

Student Information

Date of Birth:   Student ID (if assigned):

Primary Phone:   Email:

Parent / Guardian Information (if student is minor)

Relationship to Student:   Phone:

Email:

Emergency & Medical Information

Relationship:   Phone:

Health Insurance Provider:   Policy/Group #:

Permission to administer non-prescription medication (e.g., ibuprofen, antihistamines):   Yes

Tuition & Payment

Total Program Tuition: $   Deposit Required at Enrollment: $

Payment Plan (select one): Full payment at enrollment Installment plan Financial assistance / scholarship applied for

If installment plan selected, number of installments:

Deposits are required to reserve space and are non-refundable except as expressly provided below. Final balances are due in accordance with the payment schedule established by the Leadership Academy. Failure to remit payments when due may result in suspension or termination of enrollment; the enrolling party remains responsible for outstanding balances.

Scholarship / Financial Need (Optional)

Applying for need-based scholarship: Yes

Policies, Consents & Authorizations

Code of Conduct: The student agrees to comply with the Leadership Academy Code of Conduct and any rules promulgated by the Academy. Serious or repeated violations may result in disciplinary action up to and including dismissal without refund beyond the deposit amount. By checking the box below, the signatory acknowledges receipt and acceptance of the Code of Conduct.

Accept Code of Conduct: I acknowledge and accept

Photo and Media Release: I authorize the Leadership Academy to use photographs, video, or audio recordings of the student for promotional, educational, or archival purposes. No compensation will be provided. If you do NOT consent, check the box below.

Decline Photo/Media Release: I do not consent

Emergency Medical Treatment Authorization: In the event of an emergency when the parent/guardian cannot be reached, I authorize the Leadership Academy and its representatives to seek medical care for the student, including transportation to a medical facility and administration of emergency medical treatment. The enrolling party is responsible for costs incurred.

Authorize Emergency Treatment: Yes

Privacy and Records: By signing, the enrolling party authorizes the Academy to collect and retain student records necessary for program administration. The Academy may share limited information with partner organizations for legitimate program activities. Information will be handled in accordance with the Academy's privacy practices.

Liability Release: To the fullest extent permitted by law, the undersigned releases the Leadership Academy and its officers, employees, volunteers, and agents from liability for injury, loss, or damage to person or property arising from participation in Academy activities, except for willful or grossly negligent conduct. This release includes claims based on negligence and products liability.

Acknowledgment and Certification

Certification: I certify that the information provided on this Enrollment Form is true and complete to the best of my knowledge. I understand that falsification of information may be grounds for denial or revocation of enrollment. I have read and accept the tuition, payment, refund, code of conduct, emergency treatment, and liability terms set forth in this document.

Electronic Communications: The Academy may send enrollment confirmations, billing statements, and program communications via email or text to the contact information provided. It is the responsibility of the enrolling party to maintain current contact information.

Sign Now