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Membership Application

Welcome to the Young CEO Program’s membership application process. We are thrilled to provide you with a simple and comprehensible experience that allows us to truly connect with the youth of our community, their families, and our esteemed education and business partners. Our ultimate goal is to empower young minds by tackling the root causes of their challenges and equipping them with skills that guarantee tangible success. Join us on this exciting journey of transformation!

Membership Application

Youth's First Name

Youth's Last Name

Youth's Date of Birth

Gender Youth's Gender

5-Digit Zip Code

Is the applicant currently a student? School Status

Youth's Current School

Youth's Current Grade

Skills and Interests

Parent/Guardian Section

Parent/Guardian First Name

Parent Guardian Last Name

Relationship to Applicant Relation to Applicant

Parent/Guardian's Email

Parent/Guardian's Primary Phone Number

Parent/Guardian's Secondary Phone Number

Parent's Street Address

Parent's City Address

Parent/Guardian State

Parent/Guardian Zip Code

Emergency Contact Section

Primary Emergency Name

Emergency Phone 1

Emergency Phone 2

Secondary Emergency Name

Emergency Phone 1

Emergency Phone 2

Medical Information

Please check all of the medical conditions or history regarding the applicant.

*This information will remain private. However, we need it in the case of an emergency.

Medical Information Medical Care

I hereby give permission for my child to attend/participate in the Young CEO Program. In the instance of a medical emergency, I understand that Young CEO Program representatives will always attempt to contact the parent/guardian first. I hereby give permission to the Young CEO Program representative to seek emergency medical treatment. In the event I cannot be reached in an emergency, I hereby give permission to the physician to administer treatment, including hospitalization for my child/ward. I further acknowledge that there is no medical insurance coverage included in my registration for any program offered by Young CEO Program. By participating in these programs I assume my own medical responsibilities.

I hereby grant permission to the Young CEO Program to use photographs and/or videos of me taken during routine and regular activities of the YCEO in publications, news releases, online, and in other communications related to the mission of the Young CEO Program.

This form acknowledges that my child may ride to YCEO events and activities which we have a
permission slip for. If and/or when the behavior of my child becomes too distracting for the others on the van, including the driver, I acknowledge that he or she may be asked to refrain from future field trips. In consideration of the opportunity for my child to participate and fully recognizing that such an undertaking involves an element of risk, I/We assume all risks and hazards incidental to such participation and do hereby release, absolve, indemnify, and agree to hold harmless the Young CEO Program, nor shall any of said persons be held financially responsible for any injury, illness or death as a direct or indirect result of this activity. I/We, the undersigned, have read this release and understand all its terms and execute it voluntarily and with full knowledge of its significance.

Students will be dismissed from program participation for not participating in activities, not following rules, consistent discipline challenges, or any act committed deemed harmful to the student or others.

Parent/Guardian Signature Required SaveClear

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