Student Self Leadership for

Champions

1 Participant Info

Champion First Name(Required)

Champion Last Name(Required)

Email Address(Required)

Phone Number(Required)

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Address(Required)

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Preferred language?(Required)

Primary Role(Required)

Other

Do you have a student participating in the next session or who has participated in the past?

Students In Program Names

How did you hear about this program?

other

Referral Code

Taking This Class For

Organization Name

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Company Address

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HaveStudentsInProgram

YES

2 Select a date

Champion registration date(Required)

February 15, 2025