Academy of Leadership
Fall Registration Form

Due July 27^th for student leaders.
Due Aug 6^th for all others.

Applicant Information

Name:

Email address:

Address:

City:

State:

Zip:

Phone Number:

In case of emergency, please contact...
Name:
Phone Number:

I am a...
Male: Female:

Student: Staff Member:

Have you attended Academy of Leadership before?    Yes No

I am sponsored by or associated with one of the following:

Student Leadership: Athletics:
Nontraditional Student: Students with Disabilities:
Women's Services: Students with Disabilities:
Resident Assistance ( WSU Housing):
Service for International Students:
First Year Experience:
Other:

T-shirt Cut:
Men's Cut:   Women's cut:

T-Shirt Size:
Small: Medium: Large:
X-large: XX-large: XXX-large:

Accommodation and Dietary needs

Special rooming accommodations:

Dietary needs/other special needs:

Payment

Source of payment/amount   The total cost is $100.00

Personal payment amount: $

Department Sponsored amount:** $
**Department must pay in full. The student will reimburse the department for any difference in pay (i.e., If department offers to pay $40, they will pay the full $100 and the student will reimburse department $60).

Weber State University, 1107 University Circle, Ogden, Utah 84408-1107,
801-626-6000, Student Involvement

Academy of Leadership Fall Registration Form

Academy of Leadership
Fall Registration Form