2019-2020 CEO of My Life Youth IncYOUbator Enrollment Form

Select A Language

Youth Participant Information

Youth Participant's Name*

First NameLast Name

Gender*

MaleFemale

Date of Birth*

MonthDayYear

School Attending *

Current Grade Level*

Youth Participants Email Address (Teen CEO's ages 13-17 must have their own 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*

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 looking 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 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's perspective as well)*

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

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

Summer Semester Experience 2020Fall Semester Experience 2020 (Available in Atlanta and Puerto Rico Only)Spring Semester Experience 2020 (Available at Georgia Tech and Puerto Rico Only)

Please Select Your Child's Cohort (youth will be separated by their CEO level during the experience for maturity purposes)*

Youth Medical Release and Authorization

As Parent and/or Guardian of the named child, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to the CEOML Global Inc. and its affiliates including Directors to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered season.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

I Authorize*

YES

Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by CEOML Global Inc. during the selected session(s). In exchange for the acceptance of said child’s candidacy by CEOML Global Inc., I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless CEOML Global Inc. 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 CEOML Global Inc. 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

How did you hear about us?*

2019-2020 REGISTRATION FORM