LEARNERS & LEADERS COACHING & MENTORSHIP PROGRAM
Please fill all the required fields
Student's Full Name
*
First Name
Last Name
Grade
*
Please Select
8
9
10
11
12
School Info
*
School Name
School District
Student Email (Non-School)
*
example@example.com
Student Phone Number
*
Please enter a valid phone number.
Mother Full Name
*
First Name
Last Name
Mother Email
*
example@example.com
Mother Phone Number
*
Please enter a valid phone number.
Father Full Name
*
First Name
Last Name
Father Email
*
example@example.com
Father Phone Number
*
Please enter a valid phone number.
Registration
Register by Dec 10 using a code HOLIDAY to get 20% off. You will pay for the first month at the time of registration. Your card will be autocharged on the 1st of rermaining 5 months - Cancellable anytime for the future months
Registration:
*
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Learners & Leaders
The first month's payment includes a $75 Resource Fee - Cancellable anytime for future months
$
274.00
for the
first month
then,
$
199.00
for each
month
Email
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
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Confirmation
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Signature
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Date of Consent
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Month
/
Day
Year
Date
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Additional Notes/Comments
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