Purpose Driven Leadership Program Fall 2022

Purpose Driven Teen Leadership Program

Registration
Parent/Guardian 1
Parent/Guardian 1*

First NameLast Name
e-mail*
example@example.com
Mobile Phone*
Work Phone
Address*

Street Address

Street Address Line 2

CityState

Post Code
Parent/Guardian 2
Parent/Guardian 2

First NameLast Name
e-mail
example@example.com
Mobile Phone
Address

Street Address

Street Address Line 2

CityState

Post Code
Emergency Contact Details
Emergency Contact*
Relationship to Student*
Emergency Mobile Phone*
Student Info
Student Name*

First NameLast Name
Mobile Phone*
Date of Birth*

MonthDayYear
School*
Grade*
Class Days and Times by Grade

Classes begin the week of October 17th and run for 8 weeks
Select Class Grade, Day and Time*
Medical Waiver
I understand that the child will be closely supervised and that if a serious illness or injury develops, medical and/or hospital care will be given. I further understand that in case of medical emergency, I will be notified. In the event that I cannot be reached, I hereby authorize any and all emergency medical examination and/or treatment necessary for the child’s safety and welfare. I release Sire Consulting Group, any authorized employee and/or volunteer of all liability in case of accidental injury or illness.
Signature*

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Date
Registration Payment*
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Purpose Driven Teen Leadership TrainingLeadership Training
$495.00

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$0.00
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Purpose Driven Teen Leadership Program