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LIFE, LEADERSHIP, and SOCIAL SKILLS PROGRAM

REGISTRATION APPLICATION

*School Name: Enter School Name

*Student Full Name: Enter Email

*D.O.B.: Enter D.O.B.

*Street: Enter Street

*City: Enter City

*State: Enter State

*Zip code: Enter Zip

*Applicant Email: Enter Email

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*Applicant Cell Phone: Enter Your Message

Grade: Enter Text

Age: Enter Text

Gender:

M

F

*Applicant Home Telephone: Enter Text

*Parent/Guardian Email: Enter Text

*Parent/Guardian Cell Phone: Enter Text

*Home Telephone: Enter Text

*Parent/Guardian Name: Enter Text

*Parent/Guardian Signature: Enter Text

"I agree that the use of an electronic signature shall be of the same legal effect, validity, or enforceability as a manually executed signature.

Home Address

PLEASE NOTE:

If you have any questions or

need additional information call

Ted Wright (302) 270-4507 or Bill Taylor at (240) 508-4203.

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COALITION FOR PUBLIC SAFETY TRAINING IN SCHOOLS, INC.

6316 OXON HILL ROAD, #815, OXON HILL, MARYLAND 20745 · PHONE: (240) 508-4203 · EMAIL: INFO@CPSTS.ORG