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PREPARING YOUTH FOR IMPACTFUL LEADERSHIP

Rebirth Empowerment Academy

Student Leader PRE-REGISTRATION FORM

WHO CAN REGISTER/APPLY

ANY student in the 8th grade and high school can register/apply/attend the academy
ANY youth leader between the ages of 13 to 19 not attending or enrolled in school can register/apply/attend the academy
ANY CULTURE, BACKGROUND, OR LIFE EXPERIENCE...EVERY STUDENT LEADER MATTERS!

Rebirth Empowerment Academy Student Leader Registration

Full Name

Nickname or name you wish to be addressed

Date of Birth

Address

Phone

Email

Parent/Guardian Name

PARENT/GUARDIAN PHONE

PARENT/GUARDIAN EMAIL

SCHOOL

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