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Lead4Change

Student Leadership Program

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I am a:

Teacher

School Counselor

Principal / Assistant Principal

District Administrator

College Educator

Other Educator

Youth Club Adviser (not associated with a school)

Student

Parent

First Name

Last Name

Email

Password

Confirm Password

Hint: The password should be at least seven characters long. To make it stronger, use upper and lower case letters, numbers and symbols like ! " ? $ % ^ & ).

School Name

Business or Organization Name

School District

Title

Address

Address 2 (optional)

City

State

Zip / Post Code

Cell Phone (At least one of these phone number fields is required)

Cell Phone

Work Phone (At least one of these phone number fields is required)

Phone Extension (optional)

How did you hear about Lead4Change?

Conference/Workshop

Email

Lead4Change Representative

Referral

Social Media

Website

Other

Name of Referring Teacher

Please tell us if you are a member of an organization (Select All That Apply):

AFT/UFT

AMLE

ASCA

BPA

DECA

FBLA

FCCLA

FFA

HOSA

IB School

MBEA

MCEC

NCHSE

NEA

NHS

NSHSS

PTA

Student Council

None Apply

I certify that I am 13 years or older.

I understand that my information will not be shared with any other company or outside source, nor will it be made public.

I agree to be contacted specifically for the purpose of my participation in the Lead4Change Student Leadership Program.

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