Application Form: Leadership Academy
Email address *
Please note that submitting this form is an indication that you are pre-registering for the 2018 Leadership Academy.
1. Full Name (please type as you want reflected on your certificate of graduation) *
Your answer
2. Which academy will you be attending? *
Brooklyn ONLY: We offer optional childcare services ($25 per child for children ages 4 - 10/ Discount: $10 off after first child) Tell us how many children you will be registering and what ages
Ages 4 - 5
Ages 6-7
Ages 8 - 9
age 10
1 child
2 children
3 children
QUEENS ONLY: We offer interpreting services to Spanish. Will you be needing translation to Spanish? OR Can you translate from English to Spanish? *
3. Your Age *
4. Month and day of birth *
Your answer
5. What is your T-shirt size? *
6. Your preferred telephone number *
Your answer
7. Your preferred email address *
Your answer
8. Your mailing address
Your answer
9. In case of emergency who should we call (include name, telephone number & relationship to you) *
Your answer
About registration fees for LEAD Academy:
Registration fees vary by level. Fees cover graduation t-shirt or shirt, graduation certificate, dinner, etc. Fees must be paid in full on the first day of program orientation and registration. If you need financial assistance due to unemployment, homelessness, disability please indicate below.
10. Level to which you are applying *
If you need partial financial assistance to cover your registration fee, please check the box below. If not, please move on to question #11.
About you
Please take your time to share your thoughts in the questions below.
11. If this is your first time: How or where did you hear about this program? If you did the program before: Why did you decide to come back and continue? *
Your answer
12. If this is your first time in LEAD: How would you like this program to help you? If you did the program before: How did the program help you? *
Your answer
FYI: LEAD 2018 Academy Dates & Notifications:
7/1 Orientation & Academy Opens
7 /8 Academy in session
7/15 Academy in session
7/22 Dawn James-Williams Race 4 Real Survivors
7/29 Graduation

* Attendance is a mandatory requirement for graduation. Only (1) day of absence is allowed during the entire time the academies are in session.
+ In every LEAD Academy there will be movement classes. Please dress relaxed and come ready to move and have fun!

Terms of Agreement
Please read the terms below and type your name as an electronic signature.
I, the undersigned hereby give permission to 4 Real Women International, Inc.(4RWI) to the use of my photographed image or likeness, audio and video recordings on the website, magazine, brochures, social networks and other promotional venues owned and or operated by 4RWI, Inc. for promotional activities, without compensation. I further agree to hold 4 Real Women International, Inc. (4RWI) free from all claims arising from the use of said photographs, audio and video recordings and images when used within the scope described. I also release 4 Real Women International, Inc. (4RWI) of any liabilities against falls or slips on the premises, during the time of my participation in the LEAD! program. I understand that my time at The Leadership Academy 4 Women: LEAD! is my personal time for self-growth. I will attend all sessions on time, do my best to fulfill what is required of me and keep my mind focused on self-improvement. I hereby attest that all the information provided in this form is accurate and current. Should 4RWI Inc., find that this information is not current or accurate, I will automatically become ineligible for this program, even after acceptance. I also understand that if I am admitted to LEAD!, I will be required to attend a minimum of six weeks of the 4-week program in order to be eligible for the mentorship segment, to receive a certificate and participate of graduation exercises on July 29, 2018. (Type your name below) *
Your answer
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