PO Box 80932/ Conyers, GA 30013
Phone: 404-931-6641 (GA)
Fax registration form to: 904-212-1512 or
Email to: saqirah@gmail.com
Student Registration Form – Summer Leadership Program
Please Print - Student Information
Name_______________________________________________________________________
Address______________________________________________________________________
City____________________________________
Date of Birth_______________
State_____________ Zip_____________
Male___ Female____
Phone Number ________________Email Address_____________________________________
Rising Grade____ (must be a rising 6th-12th grade) T-Shirt size____________ (Small/Med/Large/XL)
Select one or more camp weeks below:
Program hours are 9am to 4pm Rates: $125/week + $25.00 Application Fee & $25 Meal Plan
Select
Week
Date
June
Week1
June
Week 2
June
Week 3
June
Week 4
June
Week 4
Campus
Location
Morehouse
Atlanta, GA
Morehouse
Atlanta, GA
Morehouse
Atlanta, GA
Morehouse
Atlanta, GA
Morehouse
Atlanta, GA
Week Overview (Teen Choice – students choose
an activity. All weeks include leadership
activities, College Tour, SAT prep & career
exploration.)
College Tour – Morehouse, Spelman, Clark Atlanta
University;
OVERNIGHT-$500.00 & $50.00 Meal Plan
Student History (Required):
We invite all teens to apply to our summer leadership program. Please disclose the following information
for your student. All information is kept confidential to TLA staff only.
1. Student GPA _______________
2. Does your child have a mental health diagnosis? If yes, please describe (including any prescribed
medications):
3. Behavior History – Describe any disciplinary issues or problems that would be reflected in the
student’s record at school, home or in the community:
FASHION
How were you referred to us? ______________________________________________
Parent Information
Parent/Guardian’s Name_______________________________________________________________
Phone_____________________Address__________________________________________________
City________________________State _______Zip_________Email___________________________
Parent Information Packet - Parent/Student Orientation
Parents will receive information packets in May. The packets will contain information for parent/student
orientation dates and times, medical forms and other documents. The packet will also include information
for the student to complete. Parents and students should complete forms and bring to orientation. During
orientation, parents and students will receive information on items to bring for overnight stays, contact
information for all staff members, camp rules, a program schedule and driving directions the university.
Georgia Campers/Residents: Parent/student orientation is scheduled for Saturday, May 30, 2015@
11:30am-1pm; Location: Morehouse College.
Refreshments will be provided. (Orientation details will be mailed or e-mail.) Please respond below as to
your intent to attend orientation:
___I plan to attend parent/student orientation. ____Estimate # of attendees
___I do not plan to attend parent/student orientation.
Transportation Information
___My son/daughter will drive a personal vehicle each day to and from camp.
___Other (please explain briefly) _________________________________________________
Deposit Due with Registration
A deposit of 50% of your total camp tuition plus a $25 application fee is due with this Registration. For
returning students – discounted registration fee is $20. Application fee waived for all registrations
received before March 15. The deposit secures the student’s space in the program. The deposit will be
deducted from the total camp fee. Remaining camp tuition is due at or before parent/student orientation.
Refund Policy
Full (100%) tuition/deposit (less application fee) will be refunded if requested in writing within 5 calendar
days of payment. No refunds after May 15. There will be no refunds or partial payments for late arrivals,
withdrawals or early departures including dismissal from camp due to rule violations.
Special Needs
Please contact us if your student requires special needs due to a physical, emotional or other condition. Due
to the demands of the camp curriculum, we will determine whether or not we can accommodate your
child’s needs.
TERMS & CONDITIONS
Tuition for the summer camp includes all field trip admission fees, workshops, parking fees, transportation
to activities and lodging (for overnight stays). Meals are not included in camp tuition. (Activities
dates/times are subject to change based on universities’ and presenters' availability. If there is a
major change in scheduling, TLA will notify parents immediately and inform parents of their
options.)
Parent/Guardian Signature__________________________________Date___________