Phoenix Center registration Application Form

Phoenix Center:

Leadership Academy Registration Form
We appreciate your time in completing the application fully, thank you!
STUDENT INFO
*For multiple students, please fill out the entire form for each student.
Name: *

First Name Last Name
Date of birth *

Month Day Year
Date Date Picker Icon

Address *

Address

Email
example@example.com
Cell Phone

Area Code Phone Number
Opt-in to Text Messages?
Emergency Contact Information

Required for Adults and Youths
Name *

First Name Last Name
Relationship to Student *
Cell Phone *

Area Code Phone Number
How did you hear about the Phoenix Center?
Course Selection & Payment
Select a course, time, and location *
TUITION: $315 includes all course materials, T-shirt, printed Academy photo and certificate upon successful completion of course

Early Bird Rate: $270 prior to August 15, 2019
*

Leadership Course Registration (Early Bird) $ 270.00

Leadership Course Registration $ 315.00

Total $ 0.00

loading smart payment buttons...

The payment is ready! It will be completed once you submit the form.
Should be Empty:

Phoenix Center: