2021 Breakaway Leader Application

"*" indicates required fields

Step 1 of 2

Breakaway Application*

1 - 19 students: 3 subsidized leader registrations

20 - 29 students: 4 subsidized leader registrations

30 - 39 students: It just keeps going….

Check with your youth pastor/director on which option to choose.

For legal purposes, this form must be filled out by the Breakaway leader applicant. No intermediary may be used.
Name*
MM slash DD slash YYYY
Gender*
T-shirt size*
Address*
Email*
Background Check*