Enroll

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

Your Title*

Please enter your title

Gender*

Male

Female

Other

Please enter your gender

First Name*

Please enter your first name

Last Name*

Please enter your last name

Home Phone*

Please enter your home phone number

Cell Phone

Please enter your cell phone number

E-mail*

Invalid email address.

Home address information

Address*

Please enter your home address

City*

Invalid Input

Zip / Postal Code*

Invalid Input

Country*

Please enter your country of residence

State*

Please enter your state

Mailing address information

Mailing Address*

Please enter your mail address

City*

Invalid Input

Zip / Postal Code*

Invalid Input

Country*

Please enter your country of residence

State*

Please enter your state

Emergency contact

Name*

Please enter the emergency contact name

Phone*

Please enter the emergency contact phone number

E-mail*

Please enter the emergency contact e-mail address

Relation*

Please enter the emergency contact relation

Section 3 - Additional Student Information

Nationality*

Please enter your nationality

Citizenship*

Please enter your citizenship

Country of Birth*

Please enter your country of birth

Education*

Please enter your education

Highest degree attained*

Please enter your highest degree attained

Year of completion*

Please enter your year of completion

Other certification

Please enter your other certifications

Section 5 - Declaration

How did you hear about the Leela School*

Please enter where you heard about the Leela School

How would you like to pay for your coursework*

In Full

3 Part payments per module

Monthly payments

Other

Please enter how you would like to pay for your coursework

Code of Ethics, Confidentiality Agreement, Policies and Signature

I have read, agree and will comply to the ACHE Code of Ethics. You can read it here *

Yes Please comply to the ACHE rules of ethics

I have read, agree and will comply to the Leela School Confidentiality Agreement. You can read it here *

Yes Please comply with the Leela School Confidentiality Agreement

I have read, agree and will comply to the Leela School Policies. You can read it here *

Yes Please comply with the Leela School Policies

I hereby declare that the information provided is true and accurate and I will inform The Leela School of any changes to the above information*

Yes Please confirm the provided information is true and accurate

Date of Signature*

Invalid Input

Your Full Name*

Please enter your full name

Your privacy is important to us. We will never sell or share your information with others.

The Leela School of Awakening

Serving Love as a True Friend

Student Enrollment Form

Section 1 - Student Details

Section 2 - Course Details

Section 3 - Additional Student Information

Section 4 - Employment and Medical

Section 5 - Declaration