GLOW Leadership Academy Registration Form

GLOW LEADERSHIP ACADEMY

Summer 2025
Camper's Information

Personal & Health & Contact
Name*

First NameLast Name
Birth Date*

MonthDayYear
Camper Race/Ethnicity*
Age (at time of camp)*
Grade (entering this fall)*
T-shirt Size:*

Youth SmallAdult SmaillYouth MediumAdult MediumYouth LargeAdult Large
Email
example@example.com
Phone Number

Area CodePhone Number
List Daughter's Current School*
List Any Allergies and Dietary Restrictions*
Medications & Frequency*
Parent / Guardian Information

(All correspondence and and invoices will be sent to this person)
Name*

First NameLast Name
Email*
example@example.com
Cell Phone*

Area CodePhone Number
Work Phone

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship to the Camper*
Emergency Contacts and Authorized Pick Up Persons*
Program Information

Program & Payment
Select Camp Week(s)*

Week 1 - June 16 - June 19 ($150)Week 2 - June 23 - June 26 ($150)Week 3 - June 30 - July 2 ($150)Week 4 - July 7 - July 10 ($150)Full GLOW Experience - All 4 Weeks ($550)
One Time Registration Fee*

$25 (Includes Camp T-shirt)
Total Cost
Date*

MonthDayYear
Date
Signature*

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USDGLOW Leadership Academy

Payment Methods

Debit or Credit Card

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

GLOW LEADERSHIP ACADEMY