SAT Prep Registration | Center for Leadership Development

First Name*
M.I.
Last Name*
Gender*
Date of Birth*
STN:
8 digit school ID
Ethnicity*
(If other, please specify)
Email*
Cell Phone*
Address 1*
Street address, P.O. box, Company name, c/o
Address 2
Apartment, suite, unit, building, floor, etc.
City*
State*
Zip*
Twitter Handle
T-Shirt Size*

Student lives with:*
Specify Other
Guardian (1)
Guardian (1) First Name*
Guardian (1) Last Name*
Guardian (1) Type*
Guardian (1) Email*
Is address same as student?
- Yes
check this box if address is the same as the students
Address (1)*
City (1)*
State (1)*
Zip (1)*
Home Phone (1)
Work Phone (1)
Cell Phone (1)
Guardian (2)
Guardian (2) First Name
Guardian (2) Last Name
Guardian (2) Type
Guardian (2) Email
Is address same as student
- Yes
check this box if address is the same as the students
Address (2)
City (2)
State (2)
Zip (2)
Home Phone (2)
Work Phone (2)
Cell Phone (2)

Current School*
Please provide complete school name (no acronyms) e.g. Warren Central High School not WCHS
Current Grade*
H.S. Graduation Year*
H.S. Graduation Year
Did your child PASS or FAIL last year?*
21st Century Scholar*
Does your child have an Individual Education Plan?*

Career Interest*
Specific Career Field

First Time in CLD Yes/No?*
If yes, how did you hear about us?
If other, please specify

The following information is REQUIRED for CLD to obtain funding as a Non-Profit Organization. Names are never used and the information is completely confidential. Your cooperation in providing this information is both appreciated and necessary
Total Number of Individuals living in household:
Annual Household Income:
Select All Programs That Apply:
- TANF
- Food Stamps
- Medicade
- SSI
- SSDI
- Veteran's Compensation
- None
Does your child receive Free or Reduced Lunch?

I hereby give permission for my child, named above, to attend and participate in Center for Leadership Development’s (CLD) programs, activities, and initiatives. For the purposes of marketing CLD programs, I hereby give permission for my child to be photographed and/or video graphed. Any data collected by CLD from various vehicles is private and confidential. Data may include, but is not limited to: ISTEP scores, CTBS, and standardized testing covered by FERPA, as well as grades, school attendance records, behavioral records and log sheets. It is also understood that data collected will protect my child’s identity, although CLD, its assigns, or successors may use the data to determine current trends. The data collected is the sole property of CLD.

I am the natural parent or legal guardian having custody of said child. In consideration of my child participating in CLD, I hereby voluntarily release and agree to hold harmless and indemnify the Center for Leadership Development (CLD), each of its directors, officers, employees, volunteers, and its partner organizations from and against any and all liability, claims, demands, actions, damages, expenses and costs, including attorney’s fees, losses and judgments of whatsoever kind and nature which may result from or arise out of my child’s participation whether or not resulting in whole or in part from negligence, acts or omissions of CLD or its directors, officers, employees, volunteers, or partner organizations, or of said child.

In the event that I cannot be reached in an emergency, I hereby give permission to the CLD staff/volunteer(s) to order x-rays, routine tests, treatment, to release any records necessary for insurance purposes, and to provide or arrange necessary related transportation for my child. In the event that I cannot be reached in an emergency, I hereby give permission to the physician or nurse selected by the CLD staff/volunteer(s) to secure and administer treatment, including hospitalization, for the youth listed above. I do hereby agree to hold free from any and all liability all respective officers, employees, and members. I hereby on behalf of my child waive, release, and forever discharge any and all rights and claims for damages which my child may have or may not have accrue arising out of or connected with my child in any of the activities of the CLD.
Parent/Guardian Printed Name*
Date*
Signature of Parent or Guardian*
Phone
This field is for validation purposes and should be left unchanged.

Programs

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Guardian (1)

Guardian (2)

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