Form

Student Name

First NameLast Name

Please complete the form for each scholar in your house hold attending.

Each scholar, needs the following for the first day of class:

1 - 1 1/2 inch binder

5 subject dividers

wide rule paper

Pencils

Highlighters

Flashcards

Date of Birth

Date

Age (must be between 11-18 as of 01/01/2023).

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian Name

First NameLast Name

Parent/Guardian Email

example@example.com

Parent/Guardian Phone Number

Please enter a valid phone number.

Gender

FemaleMale

Emergency Contact #1

First NameLast Name

Phone Number

Please enter a valid phone number.

Emergency Contact #2

First NameLast Name

Phone Number

Please enter a valid phone number.

Youth Development (select up 2 to extracurricular programming)

FootballBasketballPerforming ArtsSoccer

Middle/High School

Leadership Academy (select one location)

Monroe, LABaton Rouge, LA

School Grade/Classification (age must be between 11-18 as of 01/01/2023).

T-shirt size

Please read and accept terms and conditions (by checking) each of the following:*

I give my informed consent and permission for my son/daughter to participate in the Ivy Elite and its related activities.I agree to have my child follow all Ivy Elite guidelines and understand that any violation on my son’s/daughter’s part may result in suspension and/or termination of the mentoring, performing arts, and/or elite scholar’s academy relationship.I hereby acknowledge that son/daughter will not be transported by his/her mentor and/or Ivy Elite staff or representatives while participating in the program, and that such transportation is voluntary and at his/her and parent/legal guardian on risk.I release the Ivy Elite staff or its representatives of all liability of injury, death, or other damage to me, my son/daughter, family, estate, or heirs that may result from his/her participation in the project, including but not limited to transportation, and hold harmless any Ivy Elite mentor, volunteer, project staff, board member, or its representatives, both collectively and individually, of any injury, physical, emotional, and/or mental.I agree to allow Ivy Elite to use photographic image or name of my son/daughter taken while participating in the mentoring, elite scholar’s academy, and/or performing arts program. These images will be used in student awards, member spotlight, promotions or related marketing materials.

Signature | Parent/ Guardian (Print Name)

First NameLast Name

Signature

Clear

Elite Scholars Leadership Academy