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 NameLast Name
Date of birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
Cell Phone*
Opt-in to Text Messages?*
T-Shirt Size*
Parent info

If student is under 18
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Cell Phone

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

Required for Adults and Youths
Name*

First NameLast Name
Relationship to Student*
Cell Phone*

Area CodePhone 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
*
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Leadership Course Registration (Early Bird)$270.00

Leadership Course Registration$315.00

Total $0.00
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Phoenix Center: