Fall Retreat 2024

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Student 1

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Parent Name

*

Parent Email

*

This address will receive a confirmation email

Parent Phone

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Other Emergency Contact

*

Other Emergency Contact Number

*

Would you like to request a full or partial scholarship?

*

Please select one option.

Full Partial No Scholarship(s) Needed

Would you be willing to provide a full or partial scholarship for another student?

*

Please select one option.

Yes (Full) Yes (Partial) No

T-Shirt Size

*

Please select one option.

Small Medium Large XL XXL XXXL

Payment

1 Student ($85) 1 Justlead ($30) 2 Students ($170) 2 Justlead ($60) 3 Students ($255) 3 Justlead ($90) Will pay by cash/check later ($0) Other (Custom Amount)

Amount

Does your student have any allergies, food aversions, or medications we should know about?

*

Credit/Debit Card Number

Expiration Date/CVC

Name on Card

Card Billing Address

Description

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