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Riverside Presbyterian Church After School Program

Enrollment Form

This form is required by all participants of the Riverside Presbyterian Church After School Program. If you have any questions, please contact Paul Kerchberger, The LeaderShop's Director of Programs & Operations, at PaulK@theleadershop.org

The monthly $375 Program Fee can be paid manually or set up as a recurring payment. Please select 'One Time' for the manual payment option or 'Monthy' for the recurring payment option based on your preference. If you select 'One Time' you will need to either submit payment via The LeaderShop's 'Make A Payment' tab on our website or write a check on the 1st of each month. An Annual Registration Fee of $20 is also required to reserve your spot in the program, which can be paid through The LeaderShop's Annual Registration Form. If you wish to pay by check please drop it off in the deposit box outside the Riverside Presbyterian Church Office Door.

Registration Fee *

$375 - Monthly Tuition

Payment Schedule

Youth's Information

Youth's Name *

First Name

Last Name

Youth's Date of Birth *

(mm/dd/yyyy)

Youth's Address *

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Parent's/Guardian's Information

Parent's/Guardian's Name *

First Name

Last Name

Parent's/Guardian's Email *

Verify Email *

Parent's/Guardian's Phone *

Parent's/Guardian's Address *

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Upload Scan of Parent's/Guardian's Driver's License *

Emergency Contact's Information

Emergency Contact's Name *

First Name

Last Name

Emergency Contact's Phone *

Waiver

By checking this box, I give my child permission to participate in The LeaderShop Programs. In the event that I cannot be reached in an emergency, I give permission for staff/volunteers to take my child to a physician or to be hospitalized, secure proper treatment for and to order injections, anesthesia or surgery for my child. I hereby release and forever discharge the staff, board, and volunteers at The LeaderShop, acting officially or otherwise, from any and all claims, demands, actions, or causes of actions on account of any injury or damage which my child may sustain from any cause as a result of participating in the conference, program, or in the course of transportation. I attest and verify that my child under my supervision is medically able to participate and assume all risk of participation in this program. Further, I grant permission and a perpetual, assignable royalty free license to any and all of the foregoing to use my or my minor's image in any photographs, video tapes, motion pictures, recordings, or other record of this event for any legitimate purpose. I authorize The LeaderShop to provide transportation for my child as part of the program. I give my permission to share demographic data with a third party funder when necessary

Add 3% to my total amount to help cover the payment processing fees