Leadership School Application

What session are you applying for?

First Name *

Last Name *

Phone Number *

Email *

Street Address

City

State

Zip Code

Birth Date

Age

Gender

Do you attend church regularly?

Marital Status

Have you accepted Christ?

How did you hear about the Leadership School?

Have you gradated high school?

Are you employed?

Your health is?

List any allergies

List any physical limitations

List any medications you are using (optional)

Have you ever used illegal drugs?

Do you currently drink alcohol?

Do you currently smoke?

Have you ever been arrested or investigated for harming another

If accepted, will you make a 9 month commitment?

How will you pay your monthly program fee?

Reference 1 Name

Reference 1 Phone Number

Reference 1 Relationship To You

Reference 2 Name

Reference 2 Phone

Reference 2 Relationship To You

Reference 3 Name

Reference 3 Phone

Reference 3 Relationship To You