William R. Harvey Leadership Institute High School Summit Registration
Thank you for registering to attend the WRHLI High School Summit. We want to make the process as easy as possible. You will need to complete a separate registration and medical form for each individual attending.

If you have any questions about registration, please call 1-757-728-6698

Personal Information
Student Name
Your answer
Gender
Address
Your answer
Student Email
Your answer
Phone Number
Your answer
High School Name
Your answer
High School Address
Your answer
Last Grade Completed
Intended College Major
Your answer
Parent or Guardian Name
Your answer
Parent or Guardian Address (if different from above)
Your answer
Parent or Guardian Phone Number
Your answer
Parent or Guardian Email
Your answer
Summit Information
The registration fee for the Summit is $625. This includes a non-refundable deposit of $150 that has to be paid at the time of registration. In order to guarantee a space at the summit, your deposit will need to be made prior to April 15, 2017. Final payment of full registration fee is due prior to June 16, 2017.

Early Bird Registration: The early bird registration fee is $575. In order to qualify for this discount, you will need to pay the FULL registration fee prior to May 16, 2017.

All Summit Registration fees include room and board however, attendees will be responsible for the cost of their lunch meal on Wednesday, July 12, 2017 only.

Dietary restrictions
Required
Allergies
Your answer
Shirt Size
Summer Programs Medical Clearance Form
Required
During the Leadership Summit, we would like to capture the students in action. To do this, we would need your consent due to the student being a minor. We will not post any photos or videos of your child on our personal pages. Any photos or videos released by faculty or staff of the university will be on official pages only. If you would like to grant the William R. Harvey Leadership Institute permission to use images and/or video of your student, please sign and return the release below.
Payment Information
Once the registration form has been submitted, there will be a secure link for you to submit credit card payments. Payments in the form of Money Orders/Cashier's Checks (no personal check accepted) should be made payable to:
WILLIAM R. HARVEY LEADERSHIP INSTITUTE, HAMPTON UNIVERSITY.
Method of Payment
Amount of payment
Your answer
Purchase Order Number
Your answer
MAILED REGISTRATION FORM AND PAYMENTS WILL NEED TO BE POST MARKED PRIOR TO JUNE 16, 2017.
NO REFUNDS AFTER THIS DATE
RETURN THE COMPLETED FORM AND PAYMENT TO:
WILLIAM R. HARVEY LEADERSHIP INSTITUTE
P.O. BOX 6143
HAMPTON, VA 23668
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