Leadership for Change Staff Registration - School of Leadership and Education Sciences

Leadership for Change - Staff Registration

Thank you for agreeing to be on the staff of Leadership for Change.

Staff meeting dates and approximate times are:

Thursday, January 17: 1pm - late evening (9 pm or later) (lunch available at 12 pm) - Room 127
Friday, January 18: 8 am – 10 pm or later
Saturday, January 19: 8 am – 10 pm or later
Sunday, January 20: 8 am – 6 pm

Please provide us with the following information:

Emergency Contact Info
First Name:
Middle Name:
Last Name:
Email:
Cell phone:
Mailing address (for payment)
Street:
City:
State:
Zip:
Company Name (if applicable):
Social Security Number / tax ID:
(if you prefer, please call Beth with this information, 619-260-7790)
Title/Bio for Website: (your name, degree and professional affiliations) click here for samples
Dietary Restrictions:
Name:
Phone:
Relationship
Comments

Please click Submit only once.