Teens/Tweens Intake Form

Today's Date*

Child's Name*

First Last

Child's Place of Birth*

Child's Date of Birth*

Languages Spoken*

School Name*

Current Grade*

Child's Cell Phone # (if applicable)

Chilld's Email (if applicable)

Address*

Street Address Address Line 2 City Florida ZIP / Postal Code United States

Child's Facebook (if applicable)

Child's Instagram (if applicable)

Child's Snapchat (if applicable)

Mom's Name*

First Last

Mom's Phone Number*

Mom's Email*

Dad's Name*

First Last

Dad's Phone Number*

Dad's Email*

Parents'Relationship Status*

The child lives with the following family members: (include relationship and age)*

What made you register for our Teens/Tweens Leadership Bootcamp?*

What do you hope to get out of this 8-week Leadership Experience?*

Is there a topic you would like for us to cover in order to specifically benefit your child? Explain.

How did you hear about our Leadership Bootcamp?