Defining Leadership Registration Form

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Defining Leadership

Defining Leadership Registration Form

All fields are required. If a field is not applicable to you, please enter "n/a."

(Bolded fields are required.)

Please note: Attendance is required at all sessions, as each session builds upon the previous. Please ensure you are able to attend all program sessions before you apply.

Series applying for:

First Name:

Last Name:

Preferred Name:

Title:

Company Name:

Business Address:

City:

State:

Zip Code:

Business Phone:

Cell Phone:

Business Fax:

Business Email:

Confirm Business Email:

Home Address:

City:

State:

Zip Code:

Home Phone:

Home Email:

Confirm Home Email:

*All correspondence for the program will be sent by email. Please provide an alternate email.

Who is authorizing your participation in this program?

Name:

Title:

Email:

The Program begins with a 2-hour program orientation for you and either your supervisor or company sponsor. This person should also attend the Final Celebration with you. Please indicate who that person will be:

Name:

Title:

Email:

Are there any special accommodations that you require?

Do you have any dietary restrictions ICAN should know about?

State your education history, including degrees, dates, honors (college, graduate school, professional education).

College	Degree	Dates From/To	Honors
		from: to:
		from: to:
		from: to:

Give a brief employment history in chronological order, starting with your present position.

Organization	Dates From/To	Title/Position
	from: to:
	from: to:
	from: to:

Number of years in Supervisory Role (if applicable):

Annual Compensation:

List any leadership or management development programs attended:

Give a brief description of your career objectives:

Briefly explain why you want to participate in this series:

Have you ever attended an ICAN program?:

Yes No

Have you applied to ICAN’s Defining Leadership program before?:

Yes No

List community, civic, business, professional and social organizations in which you are an active member:

Please select those items in which you have an interest:

Being a mentor
Having a mentor
Having a professional coach

The richness of the program is increased and the learning is enhanced when differences in individuals are present. What differences in perspective would you bring?

Complete the following questions ONLY if you work for a nonprofit organization with 50 employees or less. CLICK HERE to see scholarship opportunities available.

Executive Director:

# of Employees:

	Board Members:


	Headquarters Location:


	Who recommended you for the program?


	What are your job accountabilities?


	How long have you been in this position?


	What are the current leadership and/or organizational challenges you face?


	What is the outcome you are looking to achieve upon completion of the program?


	How did you hear about the ICAN scholarship?


Web Site:

NAM Member:

Operating Budget:

If you DO NOT wish for your pictures or comments to be used in ICAN promotional materials please check the box at the left.

I UNDERSTAND THAT ALL INFORMATION SUBMITTED WILL BE USED BY THE ICAN, INC. OFFICE AND THE SELECTION COMMITTEE ONLY. FACILITATORS PLEDGE ABSOLUTE CONFIDENTIALITY REGARDING INFORMATION CONTAINED IN ALL ASSESSMENTS. I UNDERSTAND THAT SUBMISSION OF THIS COMPLETED APPLICATION INDICATES THAT BOTH MY EMPLOYER AND I HAVE REVIEWED AND ACCEPT THE PROGRAM'S REQUIRED COMMITMENT OF TIME AND FINANCIAL RESOURCES. TUITION IS NONREFUNDABLE. SUBMISSION OF A COMPLETED APPLICATION INDICATES YOU ACCEPT THESE REFUND TERMS.

I accept

Please note: Once your application is received, you will receive an email confirmation from ICAN. IF YOU DO NOT RECEIVE AN EMAIL WITHIN 3 DAYS, please contact ICAN to confirm receipt of your application.