The Leela School

Waking up from the Trance of Suffering

Page 1 of 5

Student Enrollment Form

Information and Privacy
The Leela School is committed to providing students with quality education services. The school needs to ask for personal information from students, parents and guardians so it can plan, provide and report on its services, and to monitor compliance. Personal information will only be disclosed for these purposes as permitted by law.

If you need help completing this form, including translation services, please contact the Leela School

Section 1 - Student Details

Contact information
Please enter your title
Please enter your title
Please enter your gender
Please enter your first name
Please enter your last name
Please enter your home phone number
Please enter your cell phone number
Invalid email address.
Home address information
Please enter your home address
Invalid Input
Invalid Input
Please enter your country of residence
Please enter your state
Mailing address information
Please enter your mail address
Invalid Input
Invalid Input
Please enter your country of residence
Please enter your state
Emergency contact
Please enter the emergency contact name
Please enter the emergency contact phone number
Please enter the emergency contact e-mail address
Please enter the emergency contact relation

Section 2 - Course Details

Please select the course
Please enter your reason for applying

Section 3 - Additional Student Information

Please enter your nationality
Please enter your citizenship
Please enter your country of birth
Please enter your education
Please enter your highest degree attained
Please enter your year of completion
Please enter your other certifications

Section 4 - Employment and Medical

Please enter your employment status
Please enter your field of employment
Please enter if you have a disability
Please enter areas of isability impairment
Please enter other disabilities
Please enter other accomodations

Section 5 - Declaration

Please enter where you heard about the Leela School
Please enter how you would like to pay for your coursework
Please enter your message
Code of Ethics, Confidentiality Agreement, Policies and Signature
Please comply to the ACHE rules of ethics
Please comply with the Leela School Confidentiality Agreement
Please comply with the Leela School Policies
Please confirm the provided information is true and accurate
Invalid Input
Please enter your full name