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2022 Rising CEOs Form

First Name

Last Name

Phone

Home Address

Address

City

State

Zip Code

Date of Birth

Gender Identity

Is English your main language?

Yes

Do you identify as a refugee, or immigrant?

Yes

Will you need any accommodations? If so, explain

Do you have a Startup Idea? If so give us an idea.

Name of High School?

Grade

9th Grade

10th Grade

11th Grade

12th Grade

School Address

Address

City

State

Zip Code

What do you hope to learn most out of the Rising CEOS Program?

Leadership Skills

Team Working Skills

Public Speaking Skills

Marketing Skills

Technology Skills

Entrepreneurship Skills

How to make a Business Pitch

Are you committed and able to attend the program sessions?

Yes

Do you have access to a computer and reliable internet?

Yes

Parent (s) Contact

First Name	Last Name	Phone	Email

Emergency Contact

First Name	Last Name	Phone	Email

By registering and participating in the Rising CEOs, I give Midlands African Chamber Inc, (MAC) and MAC Foundation permission to use your images or video footage, in whole or in part, alone or in combination with other images and video footage, to be displayed on its website and other official channels, and to be used for media purposes such as promotional presentations and marketing campaigns? I agree to waive any privacy and compensation rights I may have in connection with such use of your name and likeness, including any rights to written content developed in conjunction with video production, editing, and marketing.

MAC Foundation. Donate, Volunteer, Advocate. Get Started Today.

Email: [email protected]

Phone: (402) 881-0343