YOUTH LEADERSHIP CLASS 31

Congratulations and welcome to Youth Leadership Class 31!

Together with other young leaders from across St. Joseph County, you will spend the year getting to know our community, both the good and the bad, while collaborating with other young people to make our community shine.

To complete your registration, please fill out the form below. You will need a parent/guardian’s signature in several places, so before you begin, grab a parent to complete the form. It won’t take long, and you’ll be ready to accept the challenge of becoming a leader and advocate for our community!

Youth Leadership Class 32 Acceptance Forms

Step 1 of 4

25%

Name (As you would like on your nametag)(Required)

First Last

Preferred Pronouns

Youth Preferred Email(Required)

We send lots of information via email. Please, make sure you check your email on a regular basis!

Enter Email Confirm Email

Parent Email(Required)

Most communication will go to your student. From time to time, we will send updates and announcements to parents, too.

Parent Cell Phone(Required)

Just in case we need to reach you...

Address(Required)

Street Address City State ZIP Code

Food Allergies or Other Meal Considerations (Vegan, Gluten Free)

Other Situation or Accomodations

Please, note any other necessary accommodations or information that will be helpful to our program coordinators.

Photo Release (Parent Signature Required)

I grant to Leadership South Bend/Mishawaka, its representative and employees, the right to take photographs of myself/my likeness. I authorize them to use and publish the same in print. I agree that they may use such images of me/my likeness with or without my name and for any lawful purpose, including for example such purposes as publicity, yearbook, illustration, advertising, and web content. I have read and understand the above:

Printed Name of Parent(Required)

Printed Name of Participant(Required)

Date(Required)

MM slash DD slash YYYY

Medical Information and Consent to Treat(Required)

In case my child needs emergency medical attention or needs to enter the hospital for emergency treatment, consent is hereby given for treatment for my child. I also agree to assume all and full responsibility for any medical bill incurred on behalf of my child.

I give my consent to treat.

Medical Conditions

My child has the following medical conditions. We will contact you if additional information is necessary to help our staff understand and support your student.

Medications

Please, list all medications your child is currently taking.

Health Insurance Provider

Include name of provider, policy #, and phone contact.

Preferred Physicial

Name and phone number of preferred physician

Emergency Contact(Required)

Provide a contact name and number in the case a parent or guardian cannot be reached.

Liability Release(Required)

I hereby acknowledge that I have been advised and agree to understand there is no liability or responsibility of any nature on the part of Leadership SBM, the Board of Directors of Leadership SBM, and the sponsors of this event, and that attendance is voluntary. I hereby give my full consent for my child to participate in the Youth Leadership SBM program and release the aforementioned parties from any liability whatsoever.

Signature(Required)

Tuition for Youth Leadership(Required)

Leadership SBM strives to guarantee everyone selected for the program is able to participate regardless of income. Therefore, we have created a sliding scale based on family income. The following questions will help you understand the levels of tuition and the options for payment. Please, indicated your tuition level by checking the box that corresponds to your family income.

Income $100,000+ (Tuition $1,500)

Income $80,000-99,999 (Tuition $1,200)

Income $50,000-79,999 (Tuition $750)

Income $30,000-49,999 (Tuition $450)

Income under $30,000 (Tuition $100)

My child's tuition is covered by scholarship.

Additional Support

If you are not able to pay the tuition level that corresponds to your family income, there are a very limited amount of extra scholarships available. Scholarships are awarded on the basis of documented financial need and availability of monies.

Indicate here if you would like to talk to the executive director about additional aid. A parent will receive a phone call.

Payment Information

Payment may be made in full by check or credit card. Checks should be sent to Leadership SBM (Youth Leadership) 1700 Mishawka Ave Administration #159 South Bend, IN 46615 Please note, credit card fees apply. Payment plans of four monthly installments are also available. Please, indicate your payment preference below. Payment in full or the first payment installment is due by Sept. 24th.

By check (Payable to Leadership SBM-mail to address above)

By Credit Card (You will receive an invoice with a link to pay. Card fees apply)

By payment plan with check or credit card (Must fill out and sign the payment plan agreement below)

Payment Plan Information

When necessary, parents may choose to pay tuition in four monthly installments. The first payment is due on or before class orientation on September 24. Subsequent payment are due on the 15th of each month (Oct/Nov/Dec). Please, contact Kristine Hilger Carles, if you have any questions or need more information [email protected] or 574-314-9090.

I prefer to pay monthly by check

I prefer to pay by credit or debit card (you will receive an invoice link to pay each month. Credit card fees apply)

Tuition Installment Agreement

I agree to pay Youth Leadership SBM the total amount of tuition indicated above as corresponds to my family income. The amount will be paid in four (4) equal installments. The first installment is due on or before Sept. 24, 2023. Subsequent installments are due on or before the 15th of October, November, and December 2023.

Printed Name of Parent

YOUTH LEADERSHIP CLASS 31

Youth Leadership Class 32 Acceptance Forms

CONTACT

MAILING ADDRESS

CONNECT

PROGRAMS

ALUMNI

ABOUT US

DONATE