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

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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. *

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?

YES NO YES (more then 2yrs ago)

Which Cohort is your child in?

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

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.

Georgia Tech Site Summer Session- July 5-16/ $450 per week Virtual Summer Session for -June 13-24/ $350 per week Virtual Summer Session for - July 11-22/ $350 per week Puerto Rico-TASIS Dorado Summer Session- June 6-17/ $400 per week Puerto Rico-Robinson School Summer Session- June 20-July 1/ $400 per week

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. *

Invoice me for my child's Full Tuition payment due Invoice me for my child's Partial Tuition payment due

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? *

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

Enter coupon

Total

$ 0.00

Payment Methods

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Credit Card Number	Security Code
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Please click one of the PayPal options to complete payment and submit the form.

2022-2023 SUMMER SESSION REGISTRATION FORM