Group A - Spring 2025 Leaders of Distinction (L.O.D.) Program Registration Form

Spring 2025 Leaders of Distinction (L.O.D.) Program Registration Form (Group A | Ages 11-13)

Thank you for showing interest in our program! Please answer all of the questions to the best of your ability. This form will help gather important information and learn more about your child. Please ensure that your child completes the personal questions (at the end) as it relates to the program. If you are registering for more than one child, please complete a separate form for each child. Please dedicate 10-15 minutes to complete. You must complete this form in one sitting; you will be unable to exit out and come back.
PROGRAM DESCRIPTION

Girls will be divided into (2) groups by age:

Group A: 11-13

Group B: 14-17

This program aims to empower girls with leadership skills they can apply in their relationships, at school, and at home. We strive to inspire girls with increased involvement in extracurricular activities both in and outside of school. Participants in this program have the opportunity to grow into future leaders and ambassadors for Make the Distinction, with roles that may include holding leadership titles within the program.

- Lunch will be provided each week

- Topics will include, but not limited to: hygeine, phsyical and mental wellness, self esteem, relationship building, community service, and interaction with women in different professions.

Program Registration Deadline: September 15, 2025

Program will be held on Saturdays 10am-12:30pm:

10/4

10/11

10/18

10/25

11/1

11/8

11/15

11/22 - Outing

Location:

Nazarene Baptist Church

3975 Germantown Ave

Phila, PA 19140

PROGRAM REQUIREMENTS

- Girls between the ages of 11-17

- Must complete the program registration form and submit registration fee payment of $90. Registration fee is nonrefundable.

- Attendance is considered to complete the program. Must attend at least 5 out of 8 weeks to go to the outing at the end of the program.

Take a look at our Fall 2024 LOD Session

CONTACT

Website: www.makethedistinction.org

Email: contact@makethedistinction.org
Child Full Name*

First NameLast Name
Street Address*
City *
Zip Code*
Date of Birth*

MonthDayYear
Date
Age*
Name of Current School*
Grade*
Child's Cell Phone Number
Tshirt Size
Child's Email Address

Parent/Guardian Full Name *

First NameLast Name
Street Address (if same as child, leave blank)
City
Zip Code
Parent/Guardian's Relationship to Child *
Parent/Guardian's Email Address (please provide an email that you check often)*
Guardian's Cell Phone Number*

Emergency Contact Name*
Emergency Contact Phone Number
Relationship to Child*
List child's allergies and/or dietary restrictions*
List any health concerns and/or medications that we should be aware of *
Additional information
Child: How will joining this mentoring & leadership program benefit you? (please answer question in 2-3 sentences)*
Child: Name any activities you are currently involved in and outside of school (ie: sports, after school programs, the arts, gaming, etc)*
Child: List (2-3) hobbies and interests.*
Child: List (2) career/entrepreneurial interests*
MEDIA CONSENT I authorize Make The Distinction to use and publish the media in print and/or electronically. I agree that Make The Distinction may use such media of my child with or without their name and for any social media, publicity, advertising, and web content purposes. Having the ability to take pictures, videos, and other media are essential to the growth and development of our program. Make The Distinction will ensure that all pictures and videos taken of participants will be used for the development and promotion of Make The Distinction. All media will be handled responsibly and with discretion. By typing "YES", you understand and agree to the photo and video release terms. Please type "NO" if you do not agree to the photo and video release.

Please sign below to confirm completion and submission of this registration form.
Parent/Guardian Signature*

Clear
Discount Code

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.

Registration Fee*

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Spring 2025 Leaders of Distinction (L.O.D.) Program Registration Form (Group A | Ages 11-13)