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Payment Amount
$
Donation Schedule
One Time
Monthly
Quarterly
Yearly
This payment is for:
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Kids Enrichment Night
Social/Recreational Event
After School Program Fee
Camp LeaderShop
Additional information regarding what your payment is for:
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
City
State
State/Province
ZIP/Postal Code
Youth's Email
Verify Email
Youth's Township
*
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Lyons
Proviso
Berwyn
Downers Grove
Leydon
Lisle
Little Rock
Milton
Morton
Oak Park
Palos
Riverside
Stickney
Summit
Wheatland
Worth
York
Other
Youth's Grade for 2022/2023 School Year
*
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Pre-K
Kindergarten
First Grade
Second Grade
Third Grade
Fourth Grade
Fifth Grade
Sixth Grade
Seventh Grade
Eighth Grade
Freshman
Sophomore
Junior
Senior
Out of High School
Youth's School
*
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7th Ave
Argo High School
Congress Park
Cossitt
Forest Road
Graves
Gurrie
Heritage
Highlands
Hodgkins
Ideal
LTHS
Park
Riverside Brookfield
Walsh
Other
If you choose other for the school, please type the school name:
Youth's Gender
*
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Female
Male
Non-Binary
Other
Youth's Race/Ethnicity
*
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African American
African American/Caucasian
African American/Hispanic
Asian/Pacific Islander
Caucasian
Hispanic
Hispanic/Caucasian
Middle Eastern
Native American
Other (Bi-Racial)
Youth's Language
*
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English
English/Spanish
Guijarti
Lithuanian
Serbian
Slovenian
Spanish
Other
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
City
State
State/Province
ZIP/Postal Code
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