2018 JA® Entrepreneurship Summit Student Registration

Please note: A non-refundable registration fee of $25 is due at time of registration.

Student Information

Name*

First Name

Last Name

Gender*

Male Female

Age*

Date of Birth*

MM-DD-YYYY

Ethnicity*

School*

Grade Completed as of June 2018*

Student Email*

Student Phone*

Student Address*

Address Line 1

Address Line 2

City

State

ZIP Code

How did you hear about the JA® Entrepreneurship Summit*

If a person told you or referred you to the summit, please write their name here

Why do you want to attend the JA® Entrepreneurship Summit?*

Please discuss any experience you have related to entrepreneurship.*

Parent & Emergency Contact Information

Parent/Guardian Name*

First Name

Last Name

Relationship to student*

Parent/Guardian Phone*

Parent/Guardian Email*

Parent Address Same As Students?:*

Yes No

Parent/Guardian Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Emergency Contact Name*

First Name

Last Name

Emergency Contact Phone*

Transportation & Attendance Agreement

*Please note - the final location for the 2018 JA Entrepreneurship Summit is at JA Finance Park - Fairfax County (4099 Pickett Road, Fairfax, VA 22032) and the 2018 JA Entrepreneurship Summit Pitch Competition will be held at EY (1775 Tysons Blvd, Tysons, VA 22102).

Please note how the student will travel to and from the JA® Entrepreneurship Summit*

If you will ride with a friend or have selected "other," please indicate who you will be riding with, or how you will travel to and from the JA® Entrepreneurship Summit each day*

By checking this box, I recognize that Junior Achievement® is not responsible for any transportation related injuries or damages traveling to and from the facility each day

By checking this box, I understand that the JA® Entrepreneurship Summit takes place 9:00 a.m. - 2:30 p.m. on July 18, 19, 20, 23, and 24 and that my full attendance is required. Registration also requires my attendance at an evening event from 3:00 p.m. - 8:00 p.m. on July 25. Please note: if you are not able to attend all of the Summit workshops and activities, including the event on the evening of July 25, you should not register to attend this year's summit.

Health Information

To be completed by the student's parent/guardian.

Please list all food allergies or dietary restrictions. If there are none, put N/A*

Please list all drug, plant, insect, or other allergies (non food-related). If there are none, put N/A*

Please list any current or past behavioral diagnosis. If there are none, put N/A*

Please list all current medications and instructions for student's use. Students are responsible for administering their own medications. If there are none, put N/A*

Please use this space to describe any other critical information (including other medical conditions or learning disabilities) regarding the applicant. This may include accessibility needs, etc. If there are none, put N/A*

For Parent/Guardian: By signing below, I understand that Junior Achievement of Greater Washington is not liable for any physical injuries that may occur during this program. All steps have been made to ensure a safe and healthy learning environment. There will be several adult staff members supervising the students at all times. Junior Achievement of Greater Washington will immediately inform parents/guardians of any accident that may occur. Furthermore, by signing below, I am stating that this health history is correct to the best of my knowledge, and the person herein described has permission to engage in all prescribed program activities except as noted. I further agree to assume responsibility for the cost of any means of transportation related to medical care and any medical care costs are the financial responsibility of the undersigned.*

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Parents/Guardians: Use your mouse or finger to draw your signature above

Code of Ethics

To ensure the safety and well-being of all students, staff, and volunteers at the JA Entrepreneurship Summit, it is important that everyone understands and follows the same standards. Please take the time to read and sign the Code of Ethics. Student and parent/guardian signature is required below. If misconduct does occur, parent/guardian will be notified immediately.

The possession or use of alcohol, tobacco, illegal drugs or weapons is not permitted.
Students are required to stay at the facility between the hours of 9:00 a.m. and 2:30 p.m. on Wednesday July 18, Thursday July 19, Friday July 20, Monday July 23, and Tuesday July 24. The exception to this is extreme family/health emergencies.Sexual activity is not permitted.
Students are not allowed to have visitors onsite during the program.
Students must be present at and on-time to all meetings, speakers and other activities and functions.
Students must act professionally and appropriately during all speakers’ presentations, workshops, company meetings and activities. This includes, but is not limited to: not sleeping/putting head down, listening to iPods, texting, etc.
Appropriate clothing must be worn at all times during the program (details will be provided in a welcome packet to student upon program registration). Shoes and shirts are required at all times. Clothing with inappropriate or explicit language or graphics is not allowed.
JA of Greater Washington Staff maintains an environment where harassment or discrimination of any kind is unacceptable. No staff member, volunteer or program participant shall harass or discriminate against another staff member, volunteer or program participant on the basis of race, color, creed, religion, gender, age, national origin, citizenship, veteran or marital status, sexual orientation or the presence of any sensory, physical, mental handicaps or other legally protected status.

By signing below, the student and parent/guardian understand the code of ethics set forth by JA of Greater Washington and the student agrees to abide by the code of ethics at all times. Serious misconduct will be reported to your parents/guardians, principal and/or other authorities.

I understand the code of ethics set forth by Junior Achievement of Greater Washington and that any violation of this code of ethics could result in my student's behavior being reported to me, school officials, or authorities.*

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Parent/Guardian: Use your mouse or finger to draw your signature above

I understand the code of ethics set forth by Junior Achievement of Greater Washington and that any violation of this code of ethics could result in my behavior being reported to my parent/guardian, school officials, or authorities.*

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Student: Use your mouse or finger to draw your signature above

Media Release

To be completed and signed by parent/guardian.

The JA® Entrepreneurship Summit is an exciting new program that we will want to feature in Junior Achievement’s own communications as well as in the news media. Junior Achievement® and their designees have the irrevocable right and permission to:

Reproduce, use, re-use, publish, display, copyright and distribute all media taken in which your student might appear and in connection with any and all media now known or hereinafter developed, for all purposes and in perpetuity.
Reproduce, use, re-use, publish, display, copyright, and distribute the same, individually or in conjunction with other photographs, images, text, and/or captions in connection with any promotion, advertising, and publicity of Junior Achievement in all media for all purposes and in perpetuity.

Junior Achievement is released and discharged from any and all claims, demands and liability in connection with the use of such media in connection with Junior Achievement, including but not limited to claims for libel, invasion of privacy, rights of publicity and/or copyright infringement. The copyright to all media resides with Junior Achievement.

Any questions or concerns about this media release should be directed to Brea Neri, Sr. Communications Manager, at brea.neri@ja.org.

Parent/Guardian, by signing below you indicate that you understand the above media release and agree to the terms listed.*

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Use your mouse or finger to draw your signature above

Payment

Non-Refundable Application Fee: $25
Cost of Summit (due by July 1, 2018): $150

Payment is due in full by July 1, 2018. The non-refundable application fee will be deducted from the cost of the summit. However, there are several options to reduce the tuition cost for the JA® Entrepreneurship Summit. These include:

Earn $25 per friend - Recruit a friend to the Summit
Earn $25 - Create a video about the importance of students learning business skills or why JA programs are important
Earn $10 - Post about the JA Entrepreneurship Summit on Facebook (Be sure to tag Junior Achievement of Greater Washington in the post)
Earn $10 - Post about the JA Entrepreneurship Summit on Twitter (Be sure to tag @JA_GW in the post)
Earn $10 - Post about the JA Entrepreneurship Summit on Instagram (Be sure to tag @JuniorAchievementDC in the post)

*Please note if you register before June 1st, your final payment will still be based on the early bird pricing.