Conference Application

Registration Deadline has been extended to Friday, May 24, 2019
Name*
First Last
Email (Block Capitals)*
Sex*
- Male
- Female
Date of Birth (dd/mm/yy)*
Date Format: DD slash MM slash YYYY
Name of Participant School*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone (Mobile)*
Phone (Home)*
Participant Passport Number*
T-Shirt Size*
Emergency Contacts
Emergency Contact 1
Name*
First Last
Phone (Mobile)*
Phone (Home)*
Relationship to Participant*
Email*
Emergency Contact 2
Name*
First Last
Phone (Mobile)*
Phone (Home)*
Relationship to Participant*
Email*
Leadership Qualities
Why would you like the opportunity to participate in the Albert Schweitzer Leadership for Life program?
What leadership skills do you think you have?
Please give an example of how you have demonstrated leadership.
During the leadership program you will develop a leadership goal. Please give details of a goal you would like to achieve and the steps you would take to do so.
Please upload your student resume.
Accepted file types: jpg, pdf, docx.
Website
Parental Consent
Click here and fill out the form with a signature from your parent/guardian. Please send the signed form to victoria@iccusa.org
Registration Payment
Registration Fee
Price: $1,750.00
Transaction Fee
Price: $0.00
As a non-profit, we must charge a 5% fee, for any payments made by credit card. If you would like to pay by check or wire transfer, please contact us for more information.
Total
$0.00
Credit Card

American Express
Discover
MasterCard
Visa
Card Number Expiration Date Security Code Cardholder Name

Parent/Guardian Consent:
If applying through the ASLFL website, you must send a signed consent form to victoria@iccusa.org.

Photograph and Film Footage Release Statement:
I give my consent to the ICCUSA Foundation to publish and use photographs and film footage taken of my son/daughter (as named above) at the Albert Schweitzer’s Leadership for Life Conference. All materials become the property of ASLFL and may be used, without further permission, for publicity purposes including print, television or web based sources. If you have any queries in relation to the above condition, please contact ASLFL at: to discuss the matter.

Notes on completing the form:

Please ensure that you complete all sections of the form carefully.
Please ensure you include your full address as we will be sending you further information by email.
Please include a contact number as we may need to contact you directly about your application.
Selection is based on the information you provide on the form, so take the time to think about your answers.
Late applications will not be accepted so submit early to avoid disappointment.

Ensure that your parent/guardian sign the form. Applications will be returned if they are not signed.

Contact Information:
Albert Schweitzer Leadership for Life
219 South Street – Suite 203
New Providence, New Jersey 07974

Registration Deadline has been extended to Friday, May 24, 2019

Emergency Contacts

Leadership Qualities

Parental Consent

Registration Payment