EmailMe Form - Youth Leadership Exploration Retreat Application

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Name *

First MI Last

Email *

Address *

Street Address City State / Province / Region Postal / Zip Code Country / Region

Phone *

### - ### - ####

Gender *

Male

Female

Check one

Grade you will be in this upcoming Fall. *

Select one

Age *

Select one

Parent/Guardian Name *

First Last

Parent/Guardian Phone *

### - ### - ####

Organization(s) you represent

Price is based on 4 students per room. If you would like to request up to 3 room mates, please list their names below.

Price is higher for rooms with 3 or less students

Room occupancy

Basic cost of $250.00 is based on quad occupancy ( 4 students in a room). All other options cost considerably more.

You may pay online. Other payment options are money orders or cashiers check payable to: Upscale Studio, Inc.

Cash and school/organization checks are accepted, however personal checks are not accepted for payment. Deadline is Friday, June 15, 2018.

All fees are non-refundable after June 13, 2018. Request for refunds made prior to June 14, 2018 will be honored, less a $20.00 administrative fee per person. Organizations with 20 or more paid students may send one sponsor free. Other sponsors may attend for $100 each.

Total you're paying *

$ Dollars . Cents

Registration is not complete without payment. Use the "Buy Now" button located under Retreat Registration.

Thank you for supporting Upscale Studio in our efforts to impact the lives of students and promote positive opportunities for their futures. Also, to sponsor other students for our upcoming retreat or make a donation click the link button below. Your financial contributions are greatly appreciated!