SYLI Registration Form

SYLI @Goizueta Institute Registration Form

Registration for 21st Century Leaders' Summer Youth Leadership Institute (SYLI@Goizueta), taking place from Sunday, June 1st - Friday, June 6th, 2025 at Emory University in Atlanta, GA.

Step 1 of 5

Parent/Guardian Biographical Information
Parent/Guardian Name (#1)*
First Last
Parent/Guardian #1 Address
Same as student address

Street Address Address Line 2 City State ZIP Code
Parent/Guardian Email*
Please ensure email is free of errors as it will be used to send all 21CL communications. This will be the primary contact for communications from 21st Century Leaders.
Enter Email Confirm Email
Parent/Guardian Mobile*
Parent/Guardian Phone
If different from mobile number
Employer/Business Name
Position Title
Parent/Guardian Name (#2)
First Last
Address
Same as student address

Street Address Address Line 2 City State ZIP Code
Parent/Guardian Email
Please ensure email is free of errors as it will be used to send any 21CL communications.
Enter Email Confirm Email
Parent/Guardian Phone
Emergency Contact Name*
In case the parent/guardian cannot be reached; the emergency contact MUST be a person other than the parent/guardian.
Prefix First Last
Relationship to Student*
Emergency Contact Email*
Enter Email Confirm Email
Emergency Contact Phone*

21CL Entrance Survey
Please answer the following questions honestly. We would like to know more about how you see yourself as a leader today.
On a scale of 1-10 where do you see yourself as a leader?*
Where 1 is "not really a leader" and 10 is "I am the best leader ever" (Type in a number)
Please enter a number from 1 to 10.
On a scale of 1-10, how clear are you in knowing your career path after high school?*
Where 1 is "I have no idea what career I want to pursue" and 10 is "I know exactly what I want to do" (Type in a number)
Please enter a number from 1 to 10.
On a scale of 1-5, rank how developed you are in the leadership competency Communicating Effectively.*
Where 1 is "I'm not trained in this competency" and 5 is "I understand this skill and use it competently" (Type the number)
Please enter a number from 1 to 5.
On a scale of 1-5, rank how developed you are in the leadership competency Problem Solving.*
Where 1 is "I'm not trained in this competency" and 5 is "I understand this skill and use it competently" (Type the number)
Please enter a number from 1 to 5.
On a scale of 1-5, rank how developed you are in the leadership competency Action Oriented.*
Where 1 is "I'm not trained in this competency" and 5 is "I understand this skill and use it competently" (Type the number)
Please enter a number from 1 to 5.
On a scale of 1-5, rank how developed you are in the leadership competency Self Development.*
Where 1 is "I'm not trained in this competency" and 5 is "I understand this skill and use it competently" (Type the number)
Please enter a number from 1 to 5.
On a scale of 1-5, rank how developed you are in the leadership competency Building Effective Teams.*
Where 1 is "I'm not trained in this competency" and 5 is "I understand this skill and use it competently" (Type the number)
Please enter a number from 1 to 5.
On a scale of 1-5, rank how developed you are in the leadership competency Integrity & Trust.*
Where 1 is "I'm not trained in this competency" and 5 is "I understand this skill and use it competently" (Type the number)
Please enter a number from 1 to 5.
On a scale of 1-5, rank how developed you are in the leadership competency Career Ambition.*
Where 1 is "I'm not trained in this competency" and 5 is "I understand this skill and use it competently" (Type the number)
Please enter a number from 1 to 5.
How many leadership roles do you currently hold in your school, job or community?*

21CL Releases
Please read the following carefully before submitting registration.
21st Century Leaders Program Release*
You must scroll and read through the release before agreeing to the terms of service.
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, EXECUTING PARTY ACKNOWLEDGES THAT HE OR SHE HAS READ AND UNDERSTOOD ALL OF THE TERMS OF THE 21CL PROGRAM RELEASECOVENANTS AND AGREEMENTS AND THAT HE OR SHE IS VOLUNTARILY GIVING UP SUBSTANTIAL LEGAL RIGHTS, INCLUDING THE RIGHT TO SUE 21ST CENTURY LEADERS.
- I agree to the Terms of Service
21st Century Leaders Media Release*
You must scroll and read through the release before agreeing to the terms of service.
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 SIGNING, 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 Terms of Service
21st Century Leaders Code of Conduct*
You must scroll and read through the release before agreeing to the terms of service.
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 programming. 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 damages 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 Terms of Service
Student and Parent Confirmation*
You must scroll and read through the release before agreeing to the terms of service.
The Summer Youth Leadership Institute (SYLI@Goizueta) is a one-week, residential program hosted on the campus of Emory University in Atlanta, GA. The institute is held from Sunday, June 1st through Friday, June 6th, 2025.

I confirm that I will be able to attend this program. If a conflict arises, I will notify 21st Century Leaders IMMEDIATELY.
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.
- I agree to the Terms of Service
Please enter special financial code here, if applicable.
SYLI Registration Fee
SYLI @ Goizueta is an exclusive experience of residential living, access to business professionals and their companies, therefore this program comes at a small cost to participate. There is a $395.00 registration fee for this program. Please make the registration payment below:
Price:
SYLI Registration Fee
SYLI @ Goizueta is an exclusive experience of residential living, access to business professionals and their companies, therefore this program comes at a small cost to participate. There is a $395.00 registration fee for this program. Please make the registration payment below:
Price:
SYLI Registration Fee
SYLI @ Goizueta is an exclusive experience of residential living, access to business professionals and their companies, therefore this program comes at a small cost to participate. There is a $395.00 registration fee for this program. Please make the registration payment below:
Price:
SYLI Registration Fee
SYLI @ Goizueta is an exclusive experience of residential living, access to business professionals and their companies, therefore this program comes at a small cost to participate. There is a $395.00 registration fee for this program. Please make the registration payment below:
Price:
SYLI Registration Fee
SYLI @ Goizueta is an exclusive experience of residential living, access to business professionals and their companies, therefore this program comes at a small cost to participate. There is a $395.00 registration fee for this program. Please make the registration payment below:
Price:
SYLI Registration Fee
SYLI @ Goizueta is an exclusive experience of residential living, access to business professionals and their companies, therefore this program comes at a small cost to participate. There is a $395.00 registration fee for this program. Please make the registration payment below:
Price:
SYLI Registration Fee
SYLI @ Goizueta is an exclusive experience of residential living, access to business professionals and their companies, therefore this program comes at a small cost to participate. There is a $395.00 registration fee for this program. Please make the registration payment below:
Price:
SYLI Registration Fee
SYLI @ Goizueta is an exclusive experience of residential living, access to business professionals and their companies, therefore this program comes at a small cost to participate. There is a $395.00 registration fee for this program. Please make the registration payment below:
Price:
SYLI Registration Fee
SYLI @ Goizueta is an exclusive experience of residential living, access to business professionals and their companies, therefore this program comes at a small cost to participate. There is a $395.00 registration fee for this program. Please make the registration payment below:
Price:
Total
$395.00
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SYLI Registration Form

SYLI @Goizueta Institute Registration Form

Step 1 of 5

Student Biographical Information

Parent/Guardian Biographical Information

Additional Student Information

21CL Entrance Survey

21CL Releases

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