Vision In Education Leadership Student Registration
Thank you for completing this registration form.  Once completed, please request for class voucher through VIE Launchpad, Vendor #4071.  

Help us get to know your student.  Please complete all the fields on this registration form. Confirmation of class details will arrive via email within 48 hours prior to start of class.  Feel free to email me at kasama@kasamalee.com with any questions.
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Parent's Name *
Last Name, First Name
Street Address (No PO Box) *
City *
State *
Zip Code *
Student's Name *
Last Name, First Name
Student's Date of Birth *
Your student's cell phone number, if any (in case of emergency)
Parent's Cell Phone Number *
Parent's Email Address *
How did you hear about this program?  If Word of Mouth, please check "Other" and share their name so I could properly thank them! *
Your Student's Current Or Incoming Grade Level *
Which class(es) are you enrolling your student in? *
Please give me one - three words that would best describe your child. *
To bring enrichment and quality to this program, I need your help.  What are you looking to achieve from this program for your child?  What are current challenges, if any? *
Media Release: I grant to Young Leadership Academy (YLA) and its representatives the right to take photographs or videos of me and my property in connection with the above identified subject.  I authorize YLA to copyright, use and publish the same in print and/or electronically. I agree that YLA may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising and web content. *
Parents initials please.  If you choose not to participate, please type "Not Applicable" in place of your initials.
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