Effective Leadership Academy Program Registration

Registration Form - Camp LEAD/Club LEAD

Please complete the details below. If you need assistance, please contact us directly at 216-292-8775 and we’ll be happy to assist you.

Guardian Information
Guardian Name
First Last
Email*
Phone
Preferred contact number.
Phone
Work or alternative contact number.
Mailing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Program Selection
ELA Program*
Please choose Camp LEAD or Club LEAD.
Location - Camp Lead*
South Amherst Middle ($100 only - remainder grant covered): June 3-7 | Midview Middle (Grafton): June 10-14 | Lake Ridge Academy (North Ridgeville): July 15-19 | St. Anne's School of Annapolis (Annapolis, MD): July 8-12 OR July 15-19 | Saint Joseph Academy (GIRLS ONLY - Cleveland): July 15-19 | Hawken School (Lyndhurst - July 22-26) registration through hawken.edu | Hyland Software (Westlake): July 22-26 | Ahuja Medical Center (Beachwood): July 29-Aug. 2 | Lawrence School (Northfield): July 29-Aug. 2
Participant Information
Name*
First Last
New Student or Alumni?*
If the student is new to ELA programming, check NEW. If the student has gone through ELA programming before, check ALUMNI.
- NEW
- ALUMNI
Mailing Address*
Same as Guardian Address

Street Address Address Line 2 City State ZIP Code
Date of Birth*
*Mobile users: Please type in birthdate (mm/dd/yyyy) if dropdown calendar does not save selection.
Grade (2018-2019)*
Student's Current School (2018-2019)*
Gender*
We collect this information for our grant-making purposes.
- Male
- Female
- Non-Binary
GIRLS ONLY allowed at 2019 Camp LEAD at Saint Joseph Academy.
Student Email (If none, enter Guardian Email)*
Student Mobile Phone
Ethnicity (optional)
We collect this information for our grant-making purposes.
- African American
- Asian/Pacific Islander
- Caucasian (White)
- Hispanic (Non-white)
- Multi-racial
- Other
- n/a
T-Shirt Size*
Please select the participant's t-shirt size.
Emergency Contact Information
Emergency Contact Name*
First Last
Emergency Contact Phone Number*
Emergency Treatment Authorization*
In the event I cannot be reached in an emergency, I hereby give permission to the ELA Camp Director to order treatment and necessary transportation for my child to medical facilities. I give my permission to the physician/dentist to secure and administer treatment for my child named above.
- Yes
- No
Liability & Releases
Liability*
I do hereby release ELA; its officers, employees, teachers, and coaches from all liability for any accident or injury that might be sustained through participation in this program.
- Agree
- Do Not Agree
Personal Property*
I understand that ELA is not responsible for money, personal items, etc. lost during the program and I will discourage my child from bringing such items.
- Agree
- Do Not Agree
Photography Release*
I hereby grant my permission to ELA to take my child’s photo/video while participating in the camp activities to use for future publicity or video programs.
- Yes
- No
Program Scholarship
ELA Scholarship Request*
- Yes, I would like to request scholarship assistance.
- No, I do not need scholarship assistance.
Complete Scholarship Request Application
Please visit https://effectivela.org/scholarships, complete the application and submit your scholarship request within 5 business days. Once we have received the application, we will contact you and let you know within one week, maximum.
Payment Information
Camp LEAD - PRICING
Early Bird Tuition through March 31, 2019 : $275 | Tuition after March 31, 2019: $295. *Tuition may vary by location. **South Amherst Middle Camp LEAD is only $100 - remainder of cost covered by grant.***
Total
$0.00
Choose Payment Option*
Choose to pay with a credit card or by check. If paying with a credit card, after hitting submit, you will be taken to PayPal to complete your payment. Select this option if applying for scholarship assistance. If you'd prefer to pay for tuition by check, please make checks payable to Effective Leadership Academy and mail to 4480 Richmond Rd, Warrensville Heights, Ohio 44128.
- Pay by Credit Card
- Pay by Check
Feedback
How did you hear about ELA?*
Take a moment to let us know how you found out about ELA! (Choose up to 5)
Add referral name here.

Registration Form - Camp LEAD/Club LEAD

Guardian Information

Program Selection

Participant Information

Emergency Contact Information

Liability & Releases

Program Scholarship

Complete Scholarship Request Application

Payment Information

Feedback

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