Registration Form — Speak & Lead™

Program Options

🎤 Track 1 — Speak & Lead™ 4-Week Certification Course

Ages: 12–17
Dates: Tuesdays, Sept 8, 15, 22 & 29, 2026
Time: 1:00–2:30 PM
Location: Theater Room, South Cape Community Center, Cape Coral, FL
Class Size: 20 students max
Tuition: $197

Which program are you registering for?*

Student Information

Student First Name*

Student Last Name*

Preferred Name / Nickname

Birthdate*

Age*

Grade Level*

T-Shirt Size*

Has your student participated in public speaking, theater, debate, leadership, or presentation activities before?

YesNoA little

How does your student currently feel about speaking in front of others?*

Excited — give me the mic!A little nervous, but willing to tryVery nervousIt depends on the situation

Tell Me About Your Young Leader

What are your student's interests, strengths, or passions?

What would you most love to see your student gain from Speak & Lead™?*

Is there anything that helps your student feel more comfortable, engaged, or successful in a learning environment?

Does your student have any allergies, medical conditions, or physical needs the instructor should be aware of?

Learning & Support Needs

Speak & Lead™ is committed to creating an inclusive, affirming environment where every student can thrive. Sharing this information helps Angel prepare activities, pacing, and communication styles that bring out the best in your student. All information is kept strictly confidential.

Does your student have any diagnosed or suspected learning differences, neurodivergence, or developmental considerations?*

YesNoSuspected / Not Formally DiagnosedPrefer Not to Say

Please share anything that helps your student feel safe, focused, and successful — or anything that may be challenging in a group learning environment:

Would you like to request to stay on-site during the session to support your student?*

No, my student is comfortable attending independentlyYes, I would like to stay on-site (outside the room)Yes, I would like to stay in the room to support my studentI'm not sure yet — I'd like to discuss with the instructor

Is there anything else you'd like Angel to know before the first session?

Parent / Guardian Information

Parent / Guardian Full Name*

Relationship to Student*

Mobile Phone Number*

Email Address*

Home Address

City

State / ZIP

Emergency Contact Name & Phone Number*

Authorized Person(s) Who May Pick Up My Student

Scholarship & Payment

How will you be paying for this program?*

Step Up for Students ScholarshipPrivate Pay / Credit CardOther / Not Sure

If using Step Up for Students, which scholarship program does your student participate in?

I understand that registration is not complete until tuition has been paid or the required funds have been reserved through the applicable scholarship process. Space is limited, and submitting this form alone does not guarantee enrollment.*

Program Expectations & Policies

I understand that Speak & Lead™ is a supportive, high-energy learning environment where students will be encouraged to speak, present, collaborate, give and receive constructive feedback, and stretch beyond their comfort zones at their own pace. Respect for fellow students, the instructor, the learning space, and each person's unique voice is expected at all times.*

I understand that consistent attendance is strongly encouraged. Students should arrive 5–10 minutes before the scheduled start time and be picked up promptly at the end of class.*

I understand that tuition reserves my student's limited space in the program and supports materials, preparation, venue, and instructor scheduling. Missed classes are not prorated or individually refunded. If Speak & Lead™ must cancel a class due to an unforeseen circumstance, every reasonable effort will be made to reschedule the session.*

Photo & Media Permission

Please select one:*

Yes, I give permission for my student to appear in photos and videos captured during Speak & Lead™ programs for promotional, educational, website, and social media purposes.I give permission for group photos only; please do not identify my student by name.No, I do not give permission for my student to appear in promotional photos or videos.

Release & Final Acknowledgment

I understand that participation may require completion of a Speak & Lead™ Parent/Guardian Consent, Release of Liability, and Program Policies before my student attends the program.*

Parent / Guardian Electronic Signature*

Date*

Yes! Keep me in the loop about future Speak & Lead™ programs, Pop-Up Experiences, advanced courses, and student events.

Speak & Lead™Registration