Fall Learning Application - Ladies Of Leadership

Please Note* CDC GUIDELINES WILL BE IMPLEMENTED

Monday-Friday 8:00 am-3:00 pm. Before and After Care Available Upon Request (additional fee).
Breakfast and Lunch Included. $50.00 registration fee (non-refundable) / $100.00 per week (multi-child discounts) There will be an additional $2.50 credit card processing fee or you can pay with cash [due on Mondays.].
Onsite Tutoring Available. Power Packed days full of fun, learning and outdoor activities! Space is limited.

Each participant must provide their own laptop or Chromebook

First Name

Last Name

Date Of Birth

Address

City

State

Zip Code

School

Grade Completed in June 2020

Parent Name

Email *

Cell Phone

Parent Name

Cell Phone

Emergency Contact

Emergency Contact Phone

Parent/Child’s School Login Information For Grades, i.e Progress Book

Username

Parent/Child’s School Login Information For Grades, i.e Progress Book

Password

Is your child a participant in the IEP or 504 Plan?

Parent Child’s School Login Information For Grades, i.e. Progress Book

Username & Password

Is your child on a Free or Reduced-Price Lunch Program?

Allergies (medications, foods, etc)

Is your child currently on any medication that needs to be taken during the program, including inhalers?

If yes, written permission from a parent or guardian will be necessary to accompany the medication and the medications must be self-administered.

PICK UP: My child will be picked up from the program by:

(Photo ID Required)

If there is information you would like to share with us that will help maximize your child’s program experience, please contact us at the number below prior to the start of the program or provide information below.

(Include contact number)

Emergency Release: Parent/Guardian Signature I give permission, in the event of an emergency, for first aid to be administered to my child and emergency medical treatment including transportation by ambulance to the nearest hospital, should it be necessary. I understand that every effort will be made to contact me.

(By typing your name you verify that it acts as your digital signature)

Phone

✔️CLICK HERE TO PAY $50 REGISTRATION FEE (returning members)

✔️CLICK HERE TO PAY $75 REGISTRATION FEE (new members)