2022-2023 CEO of My Life Youth IncYOUbator Summer Registration Form

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Youth Participant Information

Youth Participant's Name

First NameLast Name

Gender

Date of Birth

MonthDayYear

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

CityState / Province

Postal / Zip CodeCountry

Parent/Guardian Information

Parent/ Guardian Name

First NameLast Name

Parent/Guardian Mobile Number

Parent/Guardian Home Number

Area CodePhone Number

Parent/ Guardian E-mail Address

example@example.com

Additional Parent/Guardian Name

Additional Parent/Guardian Mobile Number

Area CodePhone Number

Emergency Information

Emergency Contact's Name

First NameLast Name

Relationship

Emergency Contact Mobile Number

Area CodePhone Number

Emergency Contact Alt. Phone Number

Area CodePhone Number

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

What current talent(s) and/or skill(s) does your child have that you feel would add value to a team during their Youth IncYOUbator experience(s)?

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.

What is your child's biggest personal challenge right now? What areas do you feel your child could improve on in their personal and/or academic life?

How would you like to support your child or be involved during their time in the Virtual Youth IncYOUbator ?

Are you looking to make your child a member of the CEO of My Life Youth IncYOUbator and be trained through our pipeline each year until High School completion or will your child just attend for a fun session in the summer, fall or spring here and there?

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?

What do you feel are your child's Strengths , Weaknesses , Opportunities and Threats at this point in their life. ( we will be assessing this throughout their time in the Youth IncYOUbator experience, we just feel it's important to have the parent perspective as well)

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?

Which Cohort is your child in?

Please Select Your Session Dates (You will receive an invoice for tuition payment after submitting this registration form. The invoice must be paid at the time it's received. Your child's space is secure once the tuition invoice is satisfied. Your application will be automatically cancelled if the invoice isn't satisfied within 24 hours.

Will you be paying your child's Full Tuition or a Half Tuition payment to secure their space today? Half Tuition payments will be charged an additional $30 processing fee for the payment split. The balance for your tuition payment will be due by May 1. Half tuition payments must also be satisfied when you receive your invoice. If the partial payment isn't received within 24 hours your application will be cancelled.

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

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

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

Parent Signature

How did you hear about us?

My Products

Virtual Summer Session 1: June 15-26

For: Tween CEO's grades 6th-8th and Teen CEO's grades 9th-12th.

$550.00

Virtual Summer Session 2: June 29-July 10

For: Tween CEO's grades 6th-8th and Teen CEO's grades 9th-12th.

$550.00

Virtual Summer Session 3: July 13-24

For: Tween CEO's grades 6th-8th and Teen CEO's grades 9th-12th.

$550.00

Virtual Summer Session 4: July 27-August 7

For: Tween CEO's grades 6th-8th and Teen CEO's grades 9th-12th.

$550.00

Tiny CEO-Virtual Summer Session 1: June 22-26

For: Tiny CEO's grades 4th & 5th

$275.00

Tiny CEO-Virtual Summer Session 2: July 6-10

For: Tiny CEO's grades 4th & 5th

$275.00

Tiny CEO-Virtual Summer Session 3: July 20-24

For: Tiny CEO's grades 4th & 5th

$275.00

Virtual Fall 2020 Semester Session: October 10th-November 7th

For: Tween CEO's grades 6th-8th and Teen CEO's grades 9th-12th.

$600.00

Virtual Spring 2021 Semester Session: January 30th-March 7th

For: Tween CEO's grades 6th-8th and Teen CEO's grades 9th-12th.

$600.00

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Total

Payment Methods

Choose from one of the PayPal options to make your payment.

2022-2023 SUMMER SESSION REGISTRATION FORM

My Products

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