Effective Leadership Academy Program Registration

Registration Form - Camp LEAD 2020

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.

Program Selection
Welcome! Please choose which Camp LEAD program your student will attend.
Location - Camp Lead*
Lake Ridge Academy (N. Ridgeville): July 13-17 | Benedictine High School (BOYS ONLY - Cleveland): July 20-24 | Saint Joseph Academy (GIRLS ONLY - Cleveland): July 20-24 | Hyland Software (Westlake): July 27-31
Are you an employee of Hyland Software?*
- Yes
- No
HYLAND EMPLOYEE VERIFICATION
FOR HYLAND EMPLOYEES ONLY: If you are a Hyland employee, you can receive a special discount for Camp LEAD at the Hyland Software - Westlake Campus. Please enter your employee ID number and email address for employment verification. You may be contacted for further confirmation of employment.
HYLAND EMPLOYEE ID NUMBER*
HYLAND EMPLOYEES ONLY: Please enter your EMPLOYEE ID NUMBER.
HYLAND EMPLOYEE EMAIL ADDRESS*
HYLAND EMPLOYEES ONLY: Please enter your EMPLOYEE EMAIL ADDRESS. Note: Email must end with @hyland.com
Enter Email Confirm Email
Student Information
Please complete this section with the student's information.
New Participant or Alumni?*
If the participant is new to ELA programming, select NEW. If the participant has gone through ELA programming before, select ALUMNI.
- NEW
- ALUMNI
Student Information*
Student First Name Student Last Name
Student Date of Birth*
*Mobile users: Please type in birthdate (mm/dd/yyyy) if dropdown calendar does not save selection.
Date Format: MM slash DD slash YYYY
Student Grade*
Student Email (If none, enter Guardian Email)*
Student Mobile Phone*
Student's Current School*
Student's Current School Type*
Student Mailing Address*
Student Street Address 1 Student Street Address 2 Student City Student State Student Zip Code
Gender*
We collect this information for our grant-making purposes.
- Male
- Female
- Non-Binary
GIRLS ONLY allowed at 2020 Camp LEAD at Saint Joseph Academy.
BOYS ONLY allowed at 2020 Camp LEAD at Benedictine High School.
Ethnicity (optional)
We collect this information for our grant-making purposes.
- African American
- Asian/Pacific Islander
- Caucasian (White)
- Hispanic (Non-white)
- Multi-racial
Guardian Information
Please complete this section with your information.
Guardian Information*
Guardian First Name Guardian Last Name
Guardian Email*
Guardian Phone*
Preferred contact number.
Mailing Address*
Same as Student Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Family/Friend Pick Up Arrangements
Please list up to three additional individuals allowed to pick up your student from Camp LEAD programming.
Pick Up Arrangement 1*
Name Relationship Phone Number
Pick Up Arrangement 2
Name Relationship Phone Number
Pick Up Arrangement 3
Name Relationship Phone Number
Emergency Contact Information
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
Emergency Contact*
Please complete this section with the information of a relative/friend other than the guardian listed above.
First Name Last Name
Phone Number*
Medical Information
Student Allergies*
- Yes
- No
Allergies - Please Describe
Medications (describe)
NOTE: All medications should be handed to an ELA staff member for holding during Camp. No staff member of Camp LEAD is permitted to administer medication. Facilitators will remind children when it is time to take their medication and supervise them as they take it, so long as the parent/guardian has authorized self-administration. If the student takes no medications, please write N/A.
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.
- Agree
- Do Not Agree
Hyland Camp LEAD: Consent Form
Please complete this additional consent form specific for Hyland Camp LEAD attendees -- it will open in a new window.
Once complete, please email the form to faith@effectivela.org with subject line "Hyland Camp LEAD Consent Form for [Student Name]."
HYLAND 2020 CAMP LEAD CONSENT FORM
Scholarship Assistance
Request Scholarship Assistance
Needs-based scholarships for underserved families and those in need of financial assistance will be awarded on a first come, first serve basis and scholarship amounts are awarded based on federal income guidelines for financial aid.

If your household income is less than $33,651 for a two (2) person household or $51,243 for a four (4) person household, you may be eligible for a scholarship.

Scholarships will range from a 100% full scholarship to 75%, 50% or 25% coverage.

Full scholarships will require a $25 non-refundable registration fee.

If you believe you are qualified for scholarship assistance, please check the box and complete the Request Scholarship Assistance form with five (5) business days.
- Yes, I need scholarship assistance.
- No, I do not need scholarship assistance.
Complete Scholarship Request Application
Please visit 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
Benedictine: $95 All Other Camps: Early Bird Tuition through March 31, 2020 : $275 | Tuition after March 31, 2020: $295.
HYLAND EMPLOYEE Camp LEAD - Pricing
HYLAND EMPLOYEES ONLY: EARLY BIRD RATE: $225 THROUGH 3/31 REGULAR TUITION: $245 AFTER 3/31
Price: $245.00
Total
$0.00
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.

If you'd prefer to pay by check, please make checks payable to Effective Leadership Academy and mail to 4480 Richmond Rd., Warrensville Heights, Ohio 44128.
- Pay by Credit Card (PayPal)
- Pay by Check
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.

If you'd prefer to pay by check, please make checks payable to Effective Leadership Academy and mail to 4480 Richmond Rd., Warrensville Heights, Ohio 44128.
- Pay by Credit Card (PayPal)
- Pay by Check
Feedback
How did you hear about ELA?*
Take a moment to let us know how you found out about ELA!

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On MAC: Hold down CMD to select multiple items.

(Choose up to 5)
Add referral name here.

Registration Form - Camp LEAD 2020

Program Selection

HYLAND EMPLOYEE VERIFICATION

Student Information

Guardian Information

Family/Friend Pick Up Arrangements

Emergency Contact Information

Medical Information

Liability & Releases

Hyland Camp LEAD: Consent Form

Scholarship Assistance

Complete Scholarship Request Application

Payment Information

Feedback

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