2024-2025 Enrollment Form

First Name

Last Name

Mobile Phone Number

Date of Birth

Gender

Ethnicity

Race

Are you a U.S. Citizen?

YesNoOther

Are you a part of a Partner Organization? (select all that apply)

Mailing Street

Mailing Country

Mailing City

Mailing State

Mailing Zip/Postal Code

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I am able to attend the following Civic Leaders Fellowship in-person meetings:

     The American Opportunity Bootcamp on October 24-26 in Washington, DC
     A California trip on February 20-22 in Simi Valley, CA
     The Civic Leaders Fellowship Graduation on March 13-15 in Washington, DC

YesNo

I am able to attend the following Civic Leaders Fellowship virtual meetings:

     The Civic Leaders Fellowship Orientation on September 18-19
    The Lessons of Leadership on October 9-10
    The Exploring Your Career Workshop on November 13-14
    The January Convening on January 15-16
    The February Convening on February 5-6

YesNo

The enrollment amount of $175 assists the Ronald Reagan Institute in offsetting the cost of the three required trips for the Civic Leaders Fellowship. If this is a financial concern for you or your family, please email osheir@reaganfoundation.org.

By submitting this form, student agrees and acknowledges that failure to complete the program in full as set forth in this form will result in the student being liable to the Foundation for all out of pocket costs incurred by the Foundation in connection with the student's participation in the Program, including but not limited to any costs for student’s air fare in connection with the program.

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Cardholder First Name

Cardholder Last Name

Cardholder Email Address

Cardholder Phone Number

Billing Street Address

Billing City

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Billing Zip/Postal Code

Billing Country

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