Jerkins Leadership Academy Enrollment Application

Registration Requirements, Discount and Information

The registration fee for the tuition is non-refundable.

Pricing

Annual Tuition: (10 months)

Registration/Enrollment Fee (non-refundable): $25

The registration enrollment fee must be paid before the student’s enrollment

Middle School Grade 6-8: $500

High School Grade 9-12: $500
Required fields*

Please check here to indicate that you understand the above information
Page 1 of 5

Parent/Guardian Information
1st Parent/Guardian Name*

First NameLast Name
Cell Phone*

Area CodePhone Number
Home Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
E-mail*
example@example.com
2nd Parent/Guardian Name

First NameLast Name
Cell Phone

Area CodePhone Number
Home Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
E-mail
example@example.com
Are you new to Jerkins Leadership Academy this year?*

YesNo
Page 2 of 5

Child Information
Name of Student 1*

First NameMiddle NameLast Name
Grade in August 2025*
Birth Date*

MonthDayYear
Gender:*
If student is 8th-12 grade, please provide their e-mail and cell phone:
Student E-mail
example@example.com
Student Cell Phone Number

Area CodePhone Number
Previous School
Previous School District
Does your child receive extra help outside the classroom at his/her school? (i.e. IEP, speech therapy, reading resource, etc.)?*
Please explain the type of help he/her receives here.*
Page 3 of 5

Tuition and Additional Fees
1. Tuition and Fees

The Parent(s) agree to pay the following tuition and fees for the Student's enrollment at the Academy for the 25-26 academic year:
- Annual Tuition: $500.00 (10 months)
- Registration/Enrollment Fee (non-refundable): $25
  - Registration and Enrollment fees must be paid prior to the student’s enrollment
2. Withdrawal and Refunds

Prior to the Start of the Academic Year: If the Parent(s) withdraw the student before August 11, Start Date of 2025-26 Year, the non-refundable registration/enrollment fee will be forfeited. Any other tuition payments made will be refunded.

After the Start of the Academic Year: Upon the withdrawal of a student after August 11, the Parent(s) will be responsible for a portion of the annual tuition based on the withdrawal date. The exact prorated amount will be determined by the Academy's policy.

The Parent(s) agree to pay any outstanding balance within 10 days of the withdrawal notice.

3. Payment Schedule

The Parent(s) agree to pay the total annual cost according to the following schedule:
- Option 1: Full Payment. A single payment of $500.00 is due on or before the student's start date.
- Option 2: Semester Payments. Two equal payments of $250 each are due on or before the student's start date, and the second payment is due January 9, 2026, for the second semester.
- Option 3: 10 monthly payments of $50 are due on the 1st of each month.
- Option 4: 12 monthly payments of $41.67 are due on the 1st of each month.
4. Late Payments

Any tuition payment not received by the due date will be considered a late payment. A late fee of $5 or 10% of the outstanding balance, whichever is greater, will be assessed. The Academy reserves the right to suspend or dismiss a student for consistent non-payment of tuition and fees.
Required fields*

Please check here to indicate that you understand the above information
Page 4 of 5

PERMISSION SLIP
I hereby grant permission for my child/children to participate in Jerkins Leadership Academy activities and events and to release Jerkins Leadership Academy and its representatives from all liability arising out of my child's participation.

Please check "Yes" or "No" to provide your consent.
Required field*

YesNo
MEDIA ACKNOWLEDGMENT
I further grant permission for Jerkins Leadership Academy to use my child’s image and voice in printed & electronic materials, with the knowledge that no last names will be used on a public document.

Please check "Yes" or "No" to provide your consent.
Required field*

YesNo
Authorize your consent by typing the name of one parent or guardian here:*
Page 5 of 5
Should be Empty:

Registration Requirements, Discount and Information

Parent/Guardian Information

Child Information

Tuition and Additional Fees

PERMISSION SLIP

MEDIA ACKNOWLEDGMENT