Leadership Application

Leadership Application
Student Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
DOB*

MonthDayYear
Date
Address*

Street Address

CityState / Province

Postal / Zip Code
Email*
example@example.com
Current School Attending*
Select your shirt size.*
Student ID #*
Parent/Guardian Information*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Emergency Contact*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Relation to student*
Any allergies or health concerns, please list below:*
List 3 non-family references with name & phone # below:*
In your own words, write a 100-200 word paragraph explaining why you want to be in the leadership program. *
Please attach the following to this application: *Copy of school ID *Copy of most recent report card.*

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Thank you for your interest as a future leader of the Washington Leadership Academy.
If the application is accepted, then both the child and guardian will be called in for an interview.

WLA Directors:

Laura McDowell

Antony Robinson

Christina Valles
Should be Empty: