Leadership Academy Registration

School Name *

Names of STUDENTS attending (max of 12)

Names of SUPERVISOR 1 attending *

Supervisor Email *

Supervisor Phone *

Names of SUPERVISOR 2 attending

Supervisor Email

Supervisor Phone

Total Number of Shirts:

Small

Medium

Large

X-Large

2X-Large

I have a PO Number or will be sending a check:

• PO Number
• Sending a Check

PO Number