Emerging Leader Training

Instructions:

To complete this registration form you will need to answer a few simple questions about yourself and upload a headshot photo. The photo will be used to create a class directory. It can be candid; it does not need to be professional.

You will also need to provide contact information for the mentor you have been paired with at your organization. The mentor could be your immediate supervisor or someone else at your organization. If you are not sure of your mentor or need assistance in being paired with someone, please contact the person coordinating registration for this program at your organization before starting this form.

Participant Information

Name *

First

Last

Preferred Name

Organization Name - Please choose one of the following *

Work Address *

Address Line 1

City

State

Zip Code

Home Address *

Address Line 1

City

State

Zip Code

Are you working from home or office? *

Home
Office
Combination of home and office

Role/title *

Department/division *

Work email *

Work phone number *

Cell phone number *

Preferred contact number *

How long have you been with your current organization? *

How long have you worked in the water sector? *

Who should we contact in case of an emergency? Contact's first name, last name, relationship *

Emergency Contact Phone Number *

Please list any dietary restrictions or food allergies so that we may plan appropriately for catering.

Core will provide your number of classroom learning hours on your graduation certificate. If you have a need for more detailed documentation regarding CEU’s please provide a brief description and we will reach out to you to provide further assistance.

Upload a candid headshot photo to be used in class directory. *

Mentor Information

Mentor's Name *

First

Last

Mentor's role/title

Mentor's work email *

Mentor's address (best mailing address) *

Mentor's work phone number *

Name

Thank You!

This Emerging Leader Training is one of five professional development opportunities offered through Core Leadership, a NACWA program designed and administered in collaboration with Core Consulting.