Biographical Information Student Name*
First
Last
Email* Student's email, not your parent's.
Mobile Phone* Enter student mobile phone to receive text alerts about the event!
Gender* Other Gender
High School* If your school is not listed, select "Other."
--SELECT ONE-- Academy for Classical Education Acellus Academy Alcovy High School Alexander High School Allatoona High School Alliance Academy for Innovation Alpharetta High School Americus Sumter County High South Americus-Sumter High Apalachee High School Appling County High School Arabia Mountain High School Archer High School A. R. Johnson Health Science and Engineering Magnet School Armuchee High School Athens Academy Atlanta Classical Academy Atlanta Girls' School Atlanta International School Bacon County High School Baker County High School Baldwin High School Banneker High School Ben Franklin Academy Benjamin E. Mays High School B.E.S.T. Academy Berkmar High School Berrien High School Blair Academy Blessed Trinity Catholic High School Booker T. Washington High School Bradwell Institute Bremen High School Brooks County High School Brookstone School Brookwood High School Buford High School Burke County High School C.A. Gray Junior High School Cairo High School Calhoun County High School Calhoun High School Callaway High School Calvary Day School Cambridge High School Campbell High School (Smyrna) Capstone Academy Celina High School Cartersville High School Carter High School Carver High School (Atlanta) Carver Early College Carver STEAM Academy Cass High School Cedar Grove High School Cedar Shoals High School Cedartown High School Centennial High School Central Gwinnett High School Central High School (Bibb County) Central High School (Carroll County) Chamblee High School Chapel Hill High School Charles R. Drew Charter School (Atlanta) Charles R. Drew High School (Riverdale) Chatham Hall Chattahoochee High School Chattahoochee County High School Cherokee High School Chestatee High School Clarke Central High School Clarkston High School Clinch County High School Cobb Horizon High School Coffee High School Collins Hill High School Colonial Hills Christian Colquitt County High School Columbia High School Columbus High School Commerce High School Community Christian School Coosa High School Coretta Scott King Young Women's Leadership Academy High School Cornerstone Preparatory Academy Counterpane Covenant Christian Ministries Academy Creekside High School Crisp County High School Cristo Rey Atlanta Jesuit School Cross Creek High School Cross Keys High School Dacula High School Dade County High School Dalton High School Darlington School Davidson Fine Arts Magnet School Dawson County High School Decatur High School Deerfield-Windsor School DeKalb Early College Academy DeKalb School of the Arts Denmark High School Destiny Achiever's Charter High School Discovery High School Dodge County High School Dooly County High School Douglas County High School Drew Charter Senior Academy Druid Hills High School Dublin High School Duluth High School Dunwoody High School Dutchtown High School Eagle's Landing High School Eagles Landing Christian Academy Early County High School East Coweta High School East Forsyth High School East Jackson Comprehensive High School East Paulding High School Eastside High School Edmund Burke Academy Effingham County High School Elite Scholars Academy Emanuel County Institute Etowah High School Evans Christian Academy Evans High School Excel Christian Academy Fayette County High School Flowery Branch High School Forest Park High School Forsyth Central High School Franklin County High School Franklin Virtual High School Frederick Douglass High School Fugees Academy Fulton Leadership Academy Fulton Science Academy High School Gainesville High School G.W. Carver High School (Columbus) George Walton Comprehensive High School Georgia Connections Academy Georgia Cyber Academy Gilmer High School Global Impact Academy Glynn Academy GMC Prep HS Grayson High School Greater Atlanta Adventist Academy Greater Atlanta Christian School Greenbrier High School Griffin High School Grovetown High School G. W. Carver High School Gwinnett School of Mathematics, Science, and Technology Hart County High School H.V. Jenkins High School Habersham Central High School Hancock Central High School Hapeville Charter Career Academy Haralson County High School Hardaway High School Harlem High School Harris County High School Harrison High School Harvester Christian Academy Henry County High School Heritage Academy Heritage Classical Study Center Heritage High School Hillgrove High School Hiram High School Holy Innocents' Episcopal School Holy Spirit Prep School Homeschool/Georgia Virtual School Hope Christian Academy Houston County High School Howard High School Impact Academy Innovation Academy Jackson High School James Madison High School Jeff Davis High School Jefferson County High School John Milledge Academy Johns Creek High School Johnson High School Johnson Ferry Christian Academy Jonesboro High School Jones County High School Jordan Vocational High School Kell High School Kendrick High School Kennesaw Mountain High School Killian Hill Christian School King's Academy Kings Ridge Christian School KIPP Atlanta Collegiate High School Konos Academy LaGrange High School Lake Oconee Academy Lakeside High School (Atlanta) Lakeside High School (Evans) Lakeview Academy Lamar County High School Lambert High School Landmark Christian School Lanier High School Lanier County High School Langston Hughes High School Lassiter High School Lee County High School Liberty County High School Lithia Springs High School Lithonia High School Locust Grove High School Loganville High School Long County High School Lovejoy High School Lovett School Lowndes High School Luella High School Madison County High School Marietta High School Marion County Middle/High School Marist School Martha Ellen Stilwell School of the Arts Martin Luther King Jr. High School Mary Persons High School Maynard Jackson High School McEachern High School McIntosh County Academy McIntosh High School McNair High School Midtown High School Mill Creek High School Miller Grove High School Milton High School Mitchell County High School Model High School Mohammed School of Atlanta Montgomery County High School Morgan County High School Morrow High School Mount Pisgah Christian School Mount Vernon Presbyterian School Mountain View High School Mt. DeSales Academy Mt. Zion High School Mundy's Mill High School Murray County High School New Hampstead High School New Manchester High School Newnan High School Newton High School Norcross High School North Atlanta High School North Clayton High School North Cobb Christian School North Cobb High School North Forsyth High School North Georgia Christian Academy North Gwinnett High School North Hall High School North Oconee High School North Paulding High School North Springs Charter High School Northeast Independent Preparatory Academy Northgate High School Northside High School Northview High School Northwest High School Northwest Independent Preparatory Academy Notre Dame Academy Oglethorpe County High School Ola High School Our Lady of Mercy Catholic High School Pace Academy Parkview High School Paulding County High School Paul Duke STEM High School Peach County High School Peachtree Academy Peachtree Ridge High School Pebblebrook High School Pepperell High School Perry High School Phillips Exeter Academy Pickens High School Pike County High School Pinecrest Academy Pinewood Christian Academy Pope High School Prince Avenue Christian School Providence Christian Academy Provost Academy Georgia Putnam County High School Rabun County High School Redan High School Richmond County Technical Career Magnet Richmond Hill High School Ringgold High School River Ridge High School Riverdale High School Riverside Military Academy Riverwood International Charter School Rockdale County High School Rockdale Magnet School for Science and Technology Rome High School Ronald E. McNair High School Roswell High School Rutland High School South Atlanta High School Saint Mary's School Salem High School Sandy Creek High School Sandy Creek Highschool Savannah Arts Academy Savannah Early College Screven County High School Seckinger High School Sequoyah High School Shaw High School Shiloh High School Social Circle High School Sonoraville High School South Cobb High School South Effingham High School South Forsyth High School South Gwinnett High School South Paulding High School Southwest High School Southwest Atlanta Christian Academy Southwest DeKalb High School Southwest Georgia Academy Spalding High School Sprayberry High School St. Anne-Pacelli Catholic School St. Pius X Catholic High School St. Vincent's Academy Starrs Mill High School Stephenson High School Stockbridge High School Sumter County High School Swainsboro High School Taliaferro County High School The Blackstone Academy The Campus The Darlington School The Galloway School The Hotchkiss School The LIFE School The New School The New Schools at Carver The Paideia School The Walker School The Weber School Telfair County High School Tift County High School Tiftarea Academy Therrell High School Thomson High School Tri-Cities High School Troup County Comprehensive High School Tucker High School Twiggs County High School Union County High School Union Grove High school Unity Christian School Utopian Academy for the Arts High School Valdosta High School Valwood School Veterans High School Vidalia High School Walnut Grove High School Walton High School Ware County High School Warren County High School Wayne County High School W.D. Mohammed High School Wesleyan School West Forsyth High School West Laurens High School West Hall High School Westlake High School Westminster Schools Westover High School Westridge Christian Westside High School Whitewater High School Wheeler High School William and Reed Academy Windsor Forest High School Wisdom Academy Woodberry Forest Woodland High School Woodstock High School Woodville Thompkins High School Woodward Academy Young Americans Christian School
Other High School* If you selected OTHER for your high school, please type the name of the high school you attend.
Ethnicity* My classification is...* Additional Information County of Residence* Appling Athens-Clarke Atkinson Augusta-Richmond Bacon Baker Baldwin Banks Barrow Bartow Ben Hill Berrien Bibb Bleckley Brantley Brooks Bryan Bulloch Burke Butts Calhoun Camden Candler Carroll Catoosa Charlton Chatham Chattooga Cherokee Clay Clayton Clinch Cobb Coffee Colquitt Columbia Columbus-Muscogee Cook Coweta Crawford Crisp Cusseta-Chattahoochee Dade Dawson Decatur DeKalb Dodge Dooly Dougherty Douglas Early Echols Effingham Elbert Emanuel Evans Fannin Fayette Floyd Forsyth Franklin Fulton Georgetown-Quitman Gilmer Glascock Glynn Gordon Grady Greene Gwinnett Habersham Hall Hancock Haralson Harris Hart Heard Henry Houston Irwin Jackson Jasper Jeff Davis Jefferson Jenkins Johnson Jones Lamar Lanier Laurens Lee Liberty Lincoln Long Lowndes Lumpkin Macon Madison Marion McDuffie McIntosh Meriwether Miller Mitchell Monroe Montgomery Morgan Murray Muscogee Newton Oconee Oglethorpe Paulding Peach Pickens Pierce Pike Polk Pulaski Putnam Rabun Randolph Rockdale Schley Screven Seminole Spalding Stephens Stewart Sumter Talbot Taliaferro Tattnall Taylor Telfair Terrell Thomas Tift Toombs Towns Treutlen Troup Turner Twiggs Union Upson Walker Walton Ware Warren Washington Wayne Webster Wheeler White Whitfield Wilcox Wilkes Wilkinson Worth
Parent/Guardian Name*
First
Last
Parent/Guardian Email* Please ensure email is free of errors as it will be used to send communications about the summit.
Parent/Guardian Phone* Please provide the number at which the parent/guardian may be reached for summit communications.
Emergency Contact Name* In addition to the parent contact, please provide an emergency contact (MUST be a person other than the parent/guardian).
First
Last
Relationship to Student*
Emergency Contact Phone*
Do you qualify for free or reduced lunch? Please choose the group(s) you most identify with (if applicable):* Are you a participant of Leadership Connect and/or a 21CLub?* Select all the apply. For reporting purposes only.
Dietary Restrictions* Please select any dietary restrictions you may have. If you do not see it listed below, please choose OTHER and list the restriction. NOTE: While we try to accommodate dietary restrictions as listed, please contact us directly about special dietary needs.
Dietary: Other If you selected other, please list your dietary restrictions.
21CL Releases Please read the following carefully before submitting registration. You must FULLY SCROLL in order to select the acknowledgement box.
21st Century Leaders Program Release* You and your parent/guardian must read this section carefully:
In consideration of 21st Century Leaders' allowing the "Student" to participate in any 21st Century Leaders Program (including, but not limited to Leadership Connect, Summer Leadership Institutes, fall and winter summits, 21CLubs, Georgia Youth Leadership Awards, school-year workshops and/or service projects, and any additional 21CL branded trainings where registration is required), I, the parent/guardian, for myself and on behalf of the Student and our respective heirs, executors, administrators and assigns (in each instance, the "Executing Party"), shall defend, indemnify, release and hold harmless 21st Century Leaders (including its directors, officers, agents, employees, representatives, volunteers, successors and assigns) against any and all suits, actions, or proceedings, at law or in equity, and from any and all claims, demands, losses, judgments, fines, penalties, damages, costs, expenses, or liabilities whatsoever, that arise from or relate to the Student's participation in the Program.
Further, Executing Party hereby releases and forever discharges 21st Century Leaders (including its directors, officers, agents, employees, representatives, volunteers, successors and assigns) from any liability arising from or relating to the Student's participation in the Program.
Executing Party acknowledges that it is his or her responsibility to consult with a physician with respect to any past or present injury, illness, health problem or any other condition or medication that may affect Student's ability to safely participate in the activities of 21st Century Leaders. Executing Party further acknowledges that as an inducement for 21st Century Leaders to allow access to the Program, Student has to abide by all rules and instructions of 21st Century Leaders (collectively, the "Rules"). Failure to follow the Rules or any other act or omission by Student, as determined in the sole discretion of 21st Century Leaders, will result in termination of access to the Program.
Executing Party understands that the Program may involve activities that may be hazardous to the Student and inherently dangerous, including but not limited to being exposed to infectious diseases such as COVID-19 (collectively "Infectious Diseases" and each an "Infectious Disease"). Executing Party hereby expressly and specifically assumes the risk of damage, injury, harm or death in connection with the Program.
Executing Party acknowledges that an inherent risk of exposure to Infectious Diseases exists in any public place where people are present. By allowing the Student to participate in the Program, Executing Party agrees that the Student will (a) comply with all directives and requirements of 21st Century Leaders or any applicable governing body, agency or similar institution, as determined by 21st Century Leaders, (b) abstain from participating in the Program or coming into contact with any released parties stipulated above or participants of the Program if feeling unwell or having been exposed to an Infectious Disease or an individual infected with an Infectious Disease (c) submit to a temperature check(s) or other procedures before participating or entering any designated premises by 21st Century Leaders, (d) oblige with social distancing and other protocols, (e) frequently wash hands and/or use hand sanitizers, and (f) wear masks, covering nose and mouth as directed by 21st Century Leaders.
Executing Party will not initiate any claim, lawsuit, court or agency action, or other legal proceeding or demand against 21st Century Leaders, nor join or assist in the prosecution of any claim for money or other damages which anyone may have, on account of injuries (including death), losses, or damages sustained by the Student, other parties in connection with his or her participation in the Program, and Executing Party waives any right he or she may have to do so. This means that Executing Party cannot sue to hold 21st Century Leaders responsible for any injury, loss, or damage sustained by the Student, other parties in connection with the Program, even if it is due to the negligence, act, omission, or other fault of 21st Century Leaders.
Executing Party expressly agrees that this release is intended to be as broad and inclusive as permitted by the laws of the State of Georgia, and that this release will be governed by and interpreted in accordance with the laws of the State of Georgia without giving effect to its conflict of laws rules. Executing Party agrees that in the event that any clause or provision of this release is held to be invalid by any court of competent jurisdiction, the invalidity of that clause or provision will not affect the remaining provisions of this release, which will continue to be enforceable. Executing Party agrees that the sole and exclusive jurisdiction and venue for litigation between Executing Party and 21st Century Leaders will be a state or federal court having jurisdiction in Georgia.
BY AGREEING BELOW, EXECUTING PARTY ACKNOWLEDGES THAT HE OR SHE HAS READ AND UNDERSTOOD ALL OF THE TERMS OF THE 21CL PROGRAM RELEASE AND THAT HE OR SHE IS VOLUNTARILY GIVING UP SUBSTANTIAL LEGAL RIGHTS, INCLUDING THE RIGHT TO SUE 21ST CENTURY LEADERS.
I agree to the program release.
21st Century Leaders Code of Conduct* You and your parent/guardian must read this section carefully.
21st Century Leaders has an excellent reputation. Your conduct at every 21st Century Leaders function should make a positive contribution to extending that reputation. It is expected that students behave, use language, and dress in a manner that is consistent with the goals of developing and demonstrating professional-level leadership.
Consistent with this Code of Conduct, all participants will be expected to:
1. Behave in a non-threatening, courteous and respectful manner, refraining from language and actions that would discredit them, their school, other delegates, advisers, or 21st Century Leaders, whether in-person or online.
2. Obey all local, state, and federal laws, and all rules and regulations of the host site, college or university.
3. Refrain from the use and/or possession of alcoholic beverages, illegal drugs and weapons. Alcoholic beverages and narcotics or other controlled substances, and weapons are not permitted. Any student found in possession thereof or present where other individuals are in possession thereof will be required to leave the Program, in addition to any other consequences or measures deemed appropriate by 21st Century Leaders.
4. Refrain from the use of electronic devices during the Program. If devices are visible and/or being used during a session, first a warning will be issued. If the offense continues, the electronic device will be collected by a 21st Century Leaders staff member and returned to the owner at the end of that day's programing. If a participant refuses collection by a staff member, 21st Century Leaders will remove such an individual from the Program event and take any other measures necessary to maintain the integrity of the Program.
5. Keep advisers or 21st Century Leaders staff informed of activities and whereabouts at all times. Under no circumstances are students allowed off-campus unless accompanied by a member of the 21st Century Leaders staff. Visitors, unless approved in writing by 21st Century Leaders, are not permitted at any overnight Program or associated event. Accidents, injuries, and illnesses must be reported to the 21st Century Leaders staff immediately.
6. Observe the curfews as listed in the Program materials. Curfew is defined as being in your own assigned room by the designated hour.
7. Act as guests of the host site, corporation, college or university. 21st Century Leaders must obey the rules of these facilities. Remember there are other professionals, students, faculty, and staff on site who have rights to use and enjoyment of the facility. Trash must be placed in the proper receptacles and not left in dorm rooms or meeting room floors. Individuals causing damage to any property or furnishings will be responsible for repair or replacement. Theft or vandalism of any kind will not be tolerated and may be reported to facility officials or local police.
8. Refrain from associating or fraternizing with individuals not participating in the Program, including students of the host college or university.
Sexual Misconduct:
1. Sexual relations of any kind, including consensual sexual acts or contact or public displays of affection while participating in any 21st Century Leaders Program, are strictly prohibited.
2. Students may not have guests, i.e. individuals not residing in a designated room, as determined by 21st Century Leaders, on their floor or in their room at any time at any 21st Century Leaders Program.
3. Incidents of sexual harassment and/ or bullying, defined as comments and/or behavior of an implicitly or explicitly sexual, intimidating, or threatening nature or otherwise as determined by 21st Century Leaders, will not be tolerated, whether Student is participating in the Program in-person or virtually/online.
Disregarding or Violating this Code of Conduct:
Students who disregard or violate this Code of Conduct will be subject to disciplinary action, including, but not limited to, forfeiture of privileges to attend future 21st Century Leaders events or programs, and permanent dismissal from the Program(s). Parents and/or guardians will be notified, and 21st Century Leaders reserves the right to notify law enforcement, if applicable.
I have read this section carefully and acknowledge below to verify.
I agree to the Code of Conduct.
21st Century Leaders Media Release* You and your parent/guardian must read this section carefully.
I, the parent/guardian, for myself and on behalf of the "Student" and our respective heirs, executors, administrators and assigns, hereby grant 21st Century Leaders and its officers, directors, employees and agents (collectively, the "21st Century Leaders”) the unconditional, worldwide, perpetual, royalty-free, assignable, sublicensable, irrevocable, and unrestricted right and license to (A) use photographs or videos that may contain the Student's image or likeness or stories, literature, or narratives submitted by, or relating to, the Student, interview and/or make both visual and/or audio recordings and still images of Student (collectively, the "Content"), (B) use Student's name, voice, likeness, biographical information, and any or all of the Content in any of 21st Century Leaders programming or the promotion thereof and (C) reproduce, modify, adapt, distribute, publish, display, exhibit, market, sell, and otherwise use in any media, by any means, methods and technologies now known or hereafter to become known, either in whole or in part, the Content for commercial purposes, including, but not limited to, promoting or publicizing the 21st Century Leaders (including the fundraising activities of the 21st Century Leaders) or otherwise furthering the mission of the 21st Century Leaders (the “Authorized Purpose”). In addition, the Student and I agree that the rights granted hereunder shall include the perpetual, worldwide right of 21st Century Leaders its parents, subsidiaries, and affiliated companies and their licensees, successors and assigns to edit, telecast, cablecast, rerun, record, publish, reproduce, use, syndicate, license, print, distribute and otherwise use in any media, by any means, methods and technologies now known or hereafter to become known, either in whole or in part, the Content for commercial purposes, including, but not limited to the Authorized Purpose. 21st Century Leaders shall be under no obligation to actually use Student's name, voice, likeness and biographical information or any of the Content.
On behalf of myself, the Student, and any other applicable parties, I hereby irrevocably waive and release (1) any claims or causes of action that may now exist or may arise in the future against 21st Century Leaders or any other party, for money or otherwise, in connection with the Authorized Purpose or any other activities and uses, including, without limitation, any and all claims for libel, defamation, infringement, or invasion of privacy or publicity, and any claims and demands arising by virtue of any blurring, distortion, alteration, optical illusion, digital enhancement or use in composite form or otherwise, and (2) any right to inspect or approve of the uses made by the 21st Century Leaders of the Content. I grant, assign, transfer, and convey to the 21st Century Leaders all copyrights and other intellectual property rights the Student or I own, if any, in or to the Content.
I have the full right and authority to grant the rights herein granted in connection with the Student with respect to all media, in perpetuity, throughout the world, and no other party's permission or consent is required. I realize that this consent cannot be withdrawn after I sign this Media Release and I acknowledge that the terms of this Media Release are binding on the Student, me, and our respective heirs, legal representatives and assigns, as applicable.
BY CLICKING THE BOX BELOW, I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTOOD ALL OF THE TERMS OF THE 21st Century Media Release AND THAT I AM VOLUNTARILY GIVING UP SUBSTANTIAL LEGAL RIGHTS.
I have read this section carefully and acknowledge below to verify.
I agree to the Media Release.
Student and Parent Confirmation* I acknowledge that the 2025 Goizueta Youth Leadership Summit will take place on Saturday, January 31st, 2026 from 9:00am-4:00pm at Emory University's Goizueta Business School.
I confirm that I will be able to attend this program. If a conflict arises, I will notify 21st Century Leaders IMMEDIATELY. I acknowledge that any fees associated with this program are non-refundable. I will abide by 21CL's Code of Conduct.
I certify that I am authorized to sign this registration form and that it is true and correct. I have carefully read and reviewed each provision of this form, including all consents and releases contained herein, fully understand them, and voluntarily agree to the terms by checking the box below. By checking the box, I agree to be bound by all provisions of this registration, release, waiver, code, consent, and authorization.
Goizueta Youth Leadership Summit, 21st Century Leaders' training summit will take place on Saturday, January 31st from 9am- 4pm at the Goizueta Business School at Emory University.
I confirm that I will be able to attend this program. If a conflict arises, I will notify 21st Century Leaders IMMEDIATELY. I acknowledge that any fees associated with this program are non-refundable.
I certify that I am authorized to sign this registration form and that it is true and correct. I have carefully read and reviewed each provision of this form, including all consents and releases contained herein, fully understand them, and voluntarily agree to the terms by checking the box below. By checking the box, I agree to be bound by all provisions of this registration, release, waiver, code, consent, and authorization.
Payment Waiver Code
GYLS Registration*
Price:
There is a $20 registration fee to attend the summit. Attendance includes lunch and a takeaway item.
GYLS Registration*
Price:
Attendance includes lunch and a takeaway item.
Credit Card*
Billing Address*
Total
$0.00