Registration Form

Click to download the Registration Form in a PDF format.

School *
Student's Name: *
Student 2 Name:
Age: *
Grade: *
Teacher:
Parent / Guardin Name: *
Address: *
E-mail: *
Home Phone: *
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Cell Phone: *
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How did you hear about this program: *
Who you know may be interested in this program? Please type name and phone number.
It is okay for my child to appear on promotional materials such as website, flier and brochures. Also as a parent or guardian I also give my consent to use my written or verbal testimonial regarding the program. *
It is not okay for my child to appear on promotional materials such as website, flier and brochures. *
Please type your name here: *
Word Verification:

Payment info: Public Speaking Fee $220.00 + $20 registration fee


Checks payable to Donna Riley or an email will be sent via PayPal for payment.


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