Name (First and Last) *

Business (If retired/unemployed write N/A) *

Current title/position (write N/A if retired or unemployed) *

Address *

Email *

Business/ Professional Affiliations (civic organizations, public office, political activities)

Do you have full support of your employer for the time required to participate in Leadership? *

Yes

No

Attendance Policy *

To be counted present for class, you must be in attendance for the duration of the session. You are only allowed one absence. Any absences beyond that will disqualify you from graduation. Do you agree to this policy?

Yes

No

T-Shirt Size *

Sizes are unisex

Enter required value XS S M L XL XXL

Please list out any known food allergies *