2021 Registration Form for CEO of My Life Youth IncYOUbator

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Youth Participant Information

Youth Participant's Name *

First Name Last Name

Gender *

Male Female

Date of Birth *

Month Day Year

School Attending *

Current Grade Level

Youth Participants Email Address (You may enter your email if your child does not have one yet.)

example@example.com

Family Home Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Parent/Guardian Information

Parent/ Guardian Name *

First Name Last Name

Parent/Guardian Mobile Number *

Parent/Guardian Home Number

Area Code Phone Number

Parent/ Guardian E-mail Address *

example@example.com

Additional Parent/Guardian Name

Additional Parent/Guardian Mobile Number

Area Code Phone Number

Emergency Information

Emergency Contact's Name *

First Name Last Name

Relationship

Emergency Contact Mobile Number *

Area Code Phone Number

Emergency Contact Alt. Phone Number

Area Code Phone Number

Does the your child have any allergies, chronic illness, or medical conditions? If yes, please describe. *

Would your child like to start a business or does he or she have a great business idea? Or does your child have a career path they would like to follow (ie. doctor, attorney etc.) If your child is undecided or interested in both please indicate.

Why would you like to enroll your child in one of our experiences? What areas of growth and/or improvement are you looking to see as a result of their participation? *

Are there any areas related to life skills or future planning that you would like to see improvement in with your child? *

Has your child ever attended a CEO of My Life Youth IncYOUbator experience before?

YES NO YES (more then 2yrs ago)

During Which Semester(s) will your child be attending? *

Physical Summer Experience 2021 Virtual Summer Experience 2021 Virtual Fall Experience 2021 (Physical Session Available in Atlanta and in Puerto Rico Only) Virtual Spring Experience 2022 (Physical Session Available at Georgia Tech and in Puerto Rico Only)

Which Cohort is your child in? *

Tween CEO (grades 6th-8th) Teen CEO (grades 9th-12th)

Please Select Your Child's Session: (session dates are for both Tween & Teen CEO's) *

Virtual Summer Session 1- June 7-18 Virtual Summer Session 2- June 21-July 2 Virtual Summer Session 3- July 19-30 Physical Summer Session 1 - June 14-25 @Georgia Institute of Technology Physical Summer Session 2 - July 19-30 @Georgia Institute of Technology Virtual Fall Session- September 18-November 6 Virtual Spring Session-February 5-March 26

Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by CEO of My Life Youth IncYOUbator during the selected session(s). In exchange for the acceptance of said child’s candidacy by CEO of My Life Youth IncYOUbator, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless CEO of My Life Youth IncYOUbator and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions.

In case of injury to said child, I hereby waive all claims against CEO of My Life Youth IncYOUbator including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all sports activities, including basketball. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.

I Consent *

YES

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

I Agree *

YES

PLEASE SIGN YOUR SIGNATURE BELOW FOR CONSENT. IF YOU CAN'T PLEASE BE SURE TO SELECT THE "I AGREE' TAB ABOVE

Parent Signature *

Clear

How did you hear about us? *

TUITION PAYMENT +$30 system processing fee (save $30 when you pay the FULL TUITION fee. If you choose to make a half tuition deposit, there is an additional $30 fee that has been added to the half tuition deposit payment. If you pay a half tuition deposit to reserve your child's space, the balance will be due by May 1 for Summer Sessions. You child's space is only secure when the full tuition payment is satisfied. ) *

Physical Summer Experience Full Tuition Payment For Tween & Teen CEO's @Georgia Tech

$ 855.00 How many sessions?

Physical Summer Experience Half Tuition Deposit ($30 split payment fee added) For Tween & Teen CEO's @Georgia Tech

$ 442.50 How many sessions?

Virtual Summer Experience Full Tuition Payment For Tween & Teen CEO's

$ 655.00 How many sessions?

Virtual Summer Experience- Half Tuition Deposit ($30 split payment fee added) For Tween & Teen CEO's

$ 342.50 How many sessions?

Virtual Fall Experience Tuition For Tween & Teen CEO's

$ 655.00

Virtual Spring Experience Tuition For Tween & Teen CEO's

$ 655.00

SUMMER BEFORE & AFTER CARE BEFORE AND AFTER CARE AVAILABLE FROM 8AM-9AM AND 3PM-4PM EACH DAY, MONDAY-FRIDAY.

$ 150.00 How many sessions

Total

$ 0.00

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2021-2022 REGISTRATION FORM