2016 - 2017 ENROLLMENT FORM Please complete and send to Katie Galicia:
[email protected] For questions, please call 913.333.3923
Emerging Leaders meet on either the First Thursday, Third Thursday, or Third Tuesday of each month from 8:30 am - 12:30 pm. Please see below for class locations. First Name: _______________________________ Last Name: ______________________________________ Company Name: _________________________________ Title: ______________________________________ Company Address: ___________________________________________________________________________ City: _________________________________________ State: ____________ Zip Code: ________________ Email: ___________________________________________ Business Phone: __________________________________
DATES & LOCATIONS DT = CX Downtown | S = CX South
Mobile Phone: ____________________________________
THURSDAY SESSION 1
THURSDAY SESSION 2
TUESDAY SESSION 3
Manager Name / Signature: _________________________
9/1/16 DT 10/6/16 DT 11/3/16 S 12/1/16 DT 1/5/17 S 2/2/17 DT 3/2/17 S 4/6/17 DT 5/4/17 S 6/1/17 DT 7/6/17 S 8/3/17 DT
9/22/16 DT 10/20/16 DT 11/17/16 DT 12/15/16 DT 1/19/17 DT 2/23/17 S 3/23/17 S 4/20/17 DT 5/18/17 DT 6/22/17 DT 7/20/17 DT 8/17/17 DT
9/20/16 DT 10/18/16 DT 11/15/16 S 12/20/16 DT 1/17/17 S 2/21/17 DT 3/21/17 S 4/18/17 DT 5/16/17 S 6/20/17 DT 7/18/17 S 8/15/17 DT
LAST CLASS & GRADUATION! SESSION 1: 8/3/17 | 12:30 - 6:30 | CXDT SESSION 2: 8/17/17 | 12:30 - 6:30 | CXDT SESSION 3: 8/15/17 | 12:30 - 6:30 | CXDT
BILLING INFORMATION Billing Contact Name: ______________________________ Billing Address (if different from above): ________________
ENROLL ME FOR (check one):
__________________________________________________ __________________________________________________
THURSDAY SESSION 1
THURSDAY SESSION 2
TUESDAY SESSION 3
Billing Contact Email: ________________________________ Billing Contact Phone: _______________________ Total investment for Emerging Leaders program is $6,000 ** Non-profit scholarship recipients are responsible for $500 of the $6,000 total investment.
CX DOWNTOWN | 1020 Central St. Ste. 100 | KCMO 64105 CX SOUTH | 6201 College Blvd | Leawood | KS 66211
