Application

STUDENT NAME *

UPLODE A PICTURE OR PHOTO

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DATE OF BIRTH *

GRADE AND NAME OF SCHOOL *

MEDICAL NEEDS PLEASE EXPLAIN

CHILD'S FAVORITE SUBJECT *Math Science English/Writing Skills OTHER

PARENT/GUARDIAN *

I consent to the unrestricted use by Leading Ladies To Live (LL2L) or any person authorized by them of any photographs, recordings, interviews, videotapes motion pictures or similar visual or auditory recordings of my child. I understand that my child's image may be edited, copied exhibited, published or distributed by LL2L, and I waive the right to inspect or approve the finished product. Additionally, I waive any right to royalties or other compensation arising or related to the use of my child's image or recording. I also understand that this material may be electronically displayed via the internet or in public educational setting. There is no time limit on the validity of this release nor is there any geographic limitation of where these materials may be distributed.

We ask that every student treat each other with respect including, volunteers, and staff and mentors. Some examples of inappropriate behavior included, but are not limited to inappropriate physical/contact with others, inappropriate language, and verbal/physical threats of any kind. LL2L has zero tolerance to cyber bullying and bullying. We reserve the right to discontinue enrollment at anytime and there will be no refunds, transfers or exchanges.

DIGITAL SIGNATURE *

UPLODE SIGNATURE

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Date *

I understand that this program is for a duration of 3 months. I also understand that if I choose to continue my child's enrollment thereafter, I agree to pay the fees required to continue my child's active membership. I understand that once payment is rendered, there are no refunds, no transfers, no exchanges. I understand that it is my responsibility to disclose any and all medical needs my child may require and I hold Leading Ladies To Live harmless and not responsible for any and all health implications that may arise. I consent to electronic signing; By choosing to sign this form electronically, I confirm that this is my signature and I have the authorization to remit payment and all matters of documentation stated herein. *AgreeWaiver of Liability

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If you are submitting payment by check or money order,
make payable to: Leading Ladies To Live

If paying by check or M/O, you will also need to submit this completed application by email by saving it as a PDF and sending as an attachment in an email to support@leadingladiestolive.org SUBJECT Girls Rock Application. Your child's enrollment is not complete until payment has been fully received. Once we have received a completed application with full payment, your child's enrollment will begin 2 weeks after received date to allow for processing and delivery of care package and materials she will need to be successful in the program. For questions please email support@leadingladiestolive.org or call (480) 372-4365.