Florida Leadership Academy
Week 1 - November 2-7, 2003 Valencia Community College
Week 2 - October 31-November 5, 2004 Hillsborough Community College

Country United States		Payment Full ($1200 US)
Registrant Information:
First Name:	Last Name:			Title:			Department:
College:	Street Address:			City:			State: Zip Code: Country:
Email:	Work Phone:			Fax Number:			Method of Payment: Visa MasterCard PO Check
Supervisor Information: Name: Title: Email: Phone:			We will invoice you if additional payments are required Cancellation & Transfer Policy Before a program begins, substantial administrative costs related to your registration are incurred. Therefore, the following fees apply:
			# wks before program more than 4 weeks 3-4 weeks less than 3 weeks		substitutions Yes (no fee) Yes (no fee) Yes (no fee)	transfer fee None None $75		cancellation fee None $75 $125

By submitting this form, you are stating that you have read and agreed to the cancellation & transfer policy and accept its terms.