Leaders Club Registration - Mental Health America Boone County

Participant's Name*

First Last

Birthdate*

Grade*

Select a session

Session 1 runs for 8 weeks and session 2 runs for 12 weeks. Please select a session or both.

Select All
Session 1: Oct 3 - Dec 5
Session 2: Jan 23 - May 7

Parent #1*

First Last

Parent #1 Address*

Street Address Address Line 2 City State ZIP Code

Parent #1 Cell Phone*

Parent #1 Email*

Enter Email Confirm Email

Parent #2 Name

First Last

Parent #2 Address

If Parent #2 Address is the same as Parent #1 Address, please skip.

Street Address Address Line 2 City State ZIP Code

Parent #2 Cell Phone

Parent #2 Email

Enter Email Confirm Email

Emergency Contact*

Emergency contact other than parents

First Last

Emergency Contact Cell Phone*

Authorized Pick-up Person #1

Please inform pickup persons to bring ID in order for child to be released. You do not need to list the parents of the child that were previously added to this form.

First Last

Authorized Pick-up Person #2

Please inform pickup persons to bring ID in order for child to be released. You do not need to list the parents of the child that were previously added to this form.

First Last

Email

This field is for validation purposes and should be left unchanged.