Summer Leadership Program

We look forward to seeing you on June 14th! Please fill out the information below.

STUDENT INFORMATION:

*First Name:

*Last Name:

Preferred Name:

*Birthdate:

Age:

*Street Address:

*City:

*State:

*Zip/Postal Code:

*Home Phone:

Cell Phone:

*Student E-mail Address:

High School Attending/Grade:

Food Allergies:

*Does the student prefer vegetarian meals?
Yes No

FAMILY INFORMATION

*Parent One First Name:

*Parent One Last Name:

*Parent One Home Phone:

Parent One Work Phone:

Parent One Cell Phone:

Parent 1 Street Address (if different from above):

Parent 1 City (if different from above):

Parent 1 State (if different from above):

Parent 1 Zip (if different from above):

Parent 2 First Name:

Parent 2 Last Name:

Parent 2 Home Phone:

Parent 2 Work Phone:

Parent 2 Cell Phone:

Parent 2 Street Address (if different from above):

Parent Two City (if different from above):

Parent Two State (if different from above):

Parent Two Zip (if different from above):

EMERGENCY CONTACT INFORMATION
Please include an emergency contact other than the parents. We will make every effort to contact parents first. In the event we are unable to reach the parents, we will notify an emergency contact.

*Emergency Contact:

*Relationship to Student:

*Emergency Phone:

* [Yes, I agree]. By registering for this JLSL program, you give the Junior League of St. Louis (JLSL) permission, in connection with any photograph and/or video taken during said program of yourself, the right to use and reuse, in any manner at all, photog