LEAD Online Register for Multiple Weeks Name of Student* First Last Student's Preferred Name Student Phone NumberType of Phone NumberHomeCellWorkStudent Email Providing your email permits SSI to send periodic updates unless you opt to unsubscribe. All personal information is used solely by Student Statesmanship Institute and our partner organizations, and will not be released, rented, sold, or otherwise distributed to anyone at any time for any reason.*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Student Birthdate* Gender Male Female Student resides withBoth ParentsMotherFatherParent/Guardian Email Address - This will be our primary contact for billing, camp details, and more.* Providing your email permits SSI to send periodic updates unless you opt to unsubscribe. All personal information is used solely by Student Statesmanship Institute and our partner organizations, and will not be released, rented, sold, or otherwise distributed to anyone at any time for any reason.Please select your high school grade/education status as of Fall 2020*9101112High School GraduateSchool Type*PublicPrivateChristianCharterHomeSchool Name* Church Name and City* How did you hear about LEAD Online? Personal Referral from Family/Friends Church/School Google Search Social Media Email Other Where you referred by someone? If so, enter their name here: Have you attended LEAD before?YesNoIf Yes, returning for the:2nd Time3rd Time4th Time5th TimeAre you an SSI Onsite Alum?YesNoAn SSI Onsite is a condensed version of LEAD that you may have participated in with your school or church group. If Yes, include date & location: (Ex: Plymouth Christian Academy - 2019) Track SelectionIf you have never attended LEAD or an Onsite, then you are only eligible to participate in the House Track. If you have already participated in the House Track, or have already attended an Onsite, you are eligible for Senate. If you have completed Senate or you have completed House and finished 11th grade, then you are eligible to participate in the Advanced Track LEAD Elite. HiddenWeek 1 Track Selection: June 22-26 House (1st Time) Senate (2nd Time) LEAD Elite (Advanced Track) Skip this question if you do not wish to participate in Week 1. Select a LEAD Elite option:LEAD Elite Worldview Sessions & Advanced Legislative Simulation - $100LEAD Elite Worldview Sessions Only - $75Week 2 Track Selection: July 13-17 House (1st Time) Senate (2nd Time) LEAD Elite (Advanced Track) Skip this question if you do not wish to participate in Week 2. Select a LEAD Elite option:LEAD Elite Worldview Sessions & Advanced Legislative Simulation - $100LEAD Elite Worldview Sessions Only - $75Week 3 Track Selection: July 27-31 House (1st Time) Senate (2nd Time) LEAD Elite (Advanced Track) Skip this question if you do not wish to participate in Week 3. Select a LEAD Elite option:LEAD Elite Worldview Sessions & Advanced Legislative Simulation - $100LEAD Elite Worldview Sessions Only - $75Parent/Guardian Full Name* Relationship to Student* Parent/ Guardian Address (if different from student) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Parent/Guardian Phone NumberType of PhoneHomeCellWorkSecondary Parent/Guardian Full Name* Relationship to Student* Secondary Parent/Guardian Phone NumberType of PhoneHomeCellWorkSecondary Parent/Guardian Email Providing your email permits SSI to send periodic updates unless you opt to unsubscribe. All personal information is used solely by Student Statesmanship Institute and our partner organizations, and will not be released, rented, sold, or otherwise distributed to anyone at any time for any reason.Secondary Parent/ Guardian Address (if different from first parent/guardian) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Are there any special learning needs we should be aware of (ADD/ADHD, dyslexia, etc.)?* Yes No If yes, please explain: Are there any mental health concerns that our staff should be aware of in order to best serve your child during camp?* Yes No If yes, please explain: Please rate your student's comfort level with technology:*Just Learning/BeginnerComfortable/ProficientTechy/Highly ProficientWhat kind of internet connection do you have? Please describe and then rate in terms of Excellent, good, average, or poor.* Student Signature for Student Conduct Covenant* Digital Signatures of both the student and responsible parent are required in order to attend LEAD. The Student Statesmanship Institute’s summer program, LEAD, is Michigan's premiere biblical worldview and leadership training program for teens. We hope your experience will be enjoyable, rewarding, and challenging. The instructors, staff, and chaperones are committed to helping you grow as a leader, and they are looking forward to you participating. The development of leadership skills includes taking responsibility for your own life and conduct, and the foundation for all behavior at all times can be summed up in the word “respect.” Please read the following carefully. “Finally, all of you, live in harmony with one another, be sympathetic, love as brothers, be compassionate and humble.” 1 Peter 3:8 1. The Bible says that Christians should “think on things that are excellent” and “avoid all appearance of evil.” I will maintain the highest moral standards and maintain a clear personal witness through proper conduct and appropriate dress (see the LEAD Policies for our standards, found here: https://ssionline.org/lead/details-and-policies/). I will not drink alcoholic beverages or use tobacco in any form while participating in LEAD; I will not use any type of illegal substances, use offensive language, etc. 2. Leadership involves self-discipline, which means accepting personal responsibility to do those things which are expected of you “as unto the Lord.” Christian leadership involves servanthood. Jesus said, “Whoever wishes to become great among you shall be your servant.” I will be prompt and attentive in all classes and activities. I will display a servant attitude toward my fellow classmates, instructors, staff, and chaperones. 3. LEAD Online is an environment conducive to learning, personal growth, and friendship and strives to remain free from distractions and outside influences. I will not bring anything that would detract from this goal to the LEAD online learning environment, nor will I use the computer or internet inappropriately at any time. 4. The Bible commands us to submit to authority. It is our desire that each student has a teachable spirit and is willing to be cooperative, obedient, and respectful to any person in God-ordained authority. I will obey the rules and submit to the authority of staff, instructors, and chaperones, and obey the rules including those given in this Student Conduct Covenant. I have read and agree with all of the above. I understand that I will be expected to abide by this signed covenant. I further understand that if I choose not to abide by this signed covenant, I will face appropriate consequences, possibly even being asked to leave.Parent Signature of Permission & Understanding* I, as parent or legal guardian of the named child do hereby give permission for their attendance of the Student Statesmanship Institute’s (SSI) LEAD Online Summer Program and further state that: • I am the parent or legal guardian of the named child and that I possess all the rights, powers, and privileges of a parent or legal guardian. • I understand that I am enrolling my child in an online learning program that will use video and audio streaming technology to transmit my child’s voice and likeness to other participants, and I authorize my child to participate in all of LEAD Online’s activities including all chat and discussion forums. • I personally assume, on my child’s behalf, all risk for any harm, injury, or damages that may befall my child or is caused by my child. • I give permission to Student Statesmanship Institute to use my child’s photograph, video, oral and/or written comments to promote SSI and/or LEAD. • I understand that while Student Statesmanship Institute will endeavor to create a safe and secure learning environment, and I will also be responsible to guard login information for LEAD Online platforms and learning resources to aid in maintaining that safe and secure environment. I understand that the login information provided to me is intended only for use by my student’s participation under my supervision. . • I agree to hold Student Statesmanship Institute, their agents, officers, directors, and employees harmless and indemnify them from any injury, loss, damage, or claim of any nature arising out of or related to my child's participation in the classes and activities of LEAD Online, specifically including any negligent act or omission of the above. • I agree to hold Student Statesmanship Institute, their, agents, officers, directors, and employees harmless and indemnify them from any injury, loss, damage, or claim of any nature arising out of or related to my child's participation in the classes and activities of LEAD, specifically including any negligent act or omission of the above. I have read and agree with all of the above and I support Student Statesmanship Institute in its endeavor to provide the best possible learning environment for every child. I acknowledge that this is a legal document and I will be bound by my agreement to its terms.How much do you want to pay today? Deposit Only - $50 Per Week Full Tuition Pay LEAD Online Deposit ONLY Price: $50.00 Quantity: Please enter in the Quantity box the total number of weeks you have registered for. For example, if attending two weeks, enter "2." You will receive an email confirming your registration and displaying your remaining tuition balance.Full weeks of House, Senate, and LEAD Elite are $100 per week. Participating in only the Worldview sessions of LEAD Elite is $75 per week. In the Quantity box enter the number of weeks you registered. For example, someone registered for Senate, one full week of LEAD Elite, and one week of LEAD Elite (Worldview Only) who wants to pay in full, would enter “1” in the quantity box for “Pay LEAD Elite Tuition (Worldview Only)” and “2” in the quantity box for “Pay $100 Full Tuition.” Pay LEAD Elite Tuition (Worldview Only) Price: $75.00 Quantity: This covers full tuition for each week of LEAD Elite (Worldview Only) that you have registered for.Pay $100 Full Tution Price: $100.00 Quantity: This covers full tuition for each week of of House, Senate, or LEAD Elite (Worldview and Advanced Legislature).Total $0.00 Debit or Credit CardPlease check your Stripe API Settings. Click the "Connect with Stripe" button to use Stripe.If you wish to pay using check or another method, please contact our office at (517) 321-6233. Student Self-Diagnostic Guide Office & Mailing Address: SSI4407 W. St. Joe Hwy.Lansing, MI 48917 Phone: 517-321-6233 Email: ssi@ssionline.org