Annual Registration Form

This form is required once per year in order to maintain our records and permissions for your child. If you would like to request a discount for your family, please contact Cathy Pierson at CathyP@theleadershop.org. We strive to ensure our programs remain affordable and accessible to all families.

If you have a discount code, please type that below.

Promo Code

Registration Fee

$20

Registration Fee

$10

Registration Fee

I am interested in the following programs:

Kids Enrichment Day

After School Program- @ Riverside Presbyterian Church

After School Program- @ Walsh Elementary School (CURRENTLY AT CAPACITY)

After School Program @ La Grange Community Center (Congress Park)

After School Program- @ First United Methodist Church (Cossitt & Forest Road) (CURRENTLY AT CAPACITY)

Emerging Middle School Leaders Program

High School Leadership Program

Volunteer Opportunities

Other

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

Youth's Email

Verify Email

Youth's Phone

If you choose other for the school, please type the school name:

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