William R. Harvey Leadership Institute

Welcome to the 29th Annual William R. Harvey Leadership Institute High School Leadership Summit

Registration & Payment Form

The High School Leadership Summit is designed for rising high school Juniors or Seniors to focus on "The Leader Within." This week long, residential program provides students the opportunity to establish a plan for after graduation through several exciting and challenging workshops.

Demographic Information

Please select the Summer Program *

First Name

Middle Name

Last Name

Birthdate

Sex:

Permanent Address

Country

Street

City

Region

Postal Code

Email Address

Mobile

High School Information

High School Name

High School City

High School State

Expected High School Graduation Date

Please select the Intended College Program *

Parent/Guardian Information

Parent/Guardian Relationship

First Name of Parent/Guardian

Last Name of Parent/Guardian

Parent/Guardian Address

Country

Street

City

Region

Postal Code

Medical Clearance (REQUIRED)

Medical Clearance forms are required to be submitted for each residential attendee prior to June 5, 2026 The medical forms can be mailed or emailed to the William R. Harvey Leadership Institute. All students must be medically cleared by the Hampton University Health Center prior to attending the Leadership Summit. You may upload your medical documentation for Hampton University Health Center review via the Medicat patient portal. The directions to register your account and submit forms may be located on the Medical Clearance Requirements webpage.

Download the HamptonU. Summer Programs Medical Clearance Form (opens in a new window/tab)

Upload completed medical forms

Only PDF medical forms will be accepted. DO NOT upload pictures of the form

Photography Release Consent (REQUIRED)

During the Leadership Summit, we would like to capture photos and videos of the students in action. Since our attendees are minors, we require photography release consent from parents/guardians. We will not post any photos and/or videos of your child on our personal webpages. Any photos and/or videos released by faculty or staff of the university will be on official Hampton University websites and webpages only.

By selecting YES, below, you hereby authorize the University and those acting pursuant to its authority to: Record your child’s likeness and voice in any medium and use your child’s name in connection with these recordings;

Use, reproduce, exhibit or distribute in any medium these recordings for any purpose that the University deems appropriate, including promotional or advertising efforts.
You release the University from liability for any violation of any personal or proprietary right you or your child may have in connection with such use.
You understand all such recordings, in whatever medium, shall remain the property of the University.
You have read and fully understand the terms of this release.

Do you authorize Hampton University to use photos and/or video footage of your child?

YES, I authorize the use of photos and/or videos of my child.

NO, I do not authorize the use of photos and/or videos of my child.

Payment Details (REQUIRED)

Registration Fee: $1,250.00 Until May 29, 2026 Must be paid in full (credit card only).
LATE Registration Fee: $1,750.00
- May 30 - June 5, 2026 Must be paid in full by June 5, 2026 - (credit card only), 12:00 p.m
Telephone: 757-728-6698

Payment link - https://pci.jotform.com/form/260763844905061

Please Enter Your Payment Invoice ID Number:

Additional Information

Dietary Restrictions *

List Other Dietary Restrictions

Allergies * (Please list)

Requested Roommate *

YES

NO

If yes, first, middle Initial and last name of participant as preferred roommate

Submit App