KP Member Registration Form

New Key Player Application

C12 Key Player Group participation is targeted to growing leaders of C12 Member Companies who desire to be developed as leaders, and equipped to understand and contribute to the purpose, vision, and performance of companies to which they have been called.
Full Name

First NameLast Name
Mobile Number

Area CodePhone Number
E-mail
Birthday

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Company Name
Business Title
E.g., Manager, VP, Supervisor
Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Is the owner or CEO of your company already a C12 member?
C12 Member Name

First NameLast Name
Accounting Email
This is the email address you prefer for invoices from C12.
How will your registration and dues be paid?
Has your C12 Chair explained the billing process to you?
What is the registration fee?
What are the monthly dues?
Functional Responsibilities
Briefly describe your role(s) and responsibilities
Spouse's Name (if married)

First NameLast Name
Anniversay (if married)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Membership Basics
Members meet monthly on a regular day (e.g., the 3rd Thursday of each month) and commit to faithful attendance. This is defined as attending at least 10 of 12 monthly meetings yearly and avoiding absence at two consecutive meetings. The effective functioning of group relationships relies on the stability, timeliness, and understanding which accompany faithful attendance and transparency. Members generally have sufficient control over their calendars to enable such participation.
Key Player Business Forum
Membership Start Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearThe month indicated is your first billing month.
C12 Membership Agreements (please check all)
What is most important for you to gain from your Key Player experience? (check all that apply)

Other
Which leadership focus area do you most need support with right now? (check all that apply)

Other
When collaborating with others, which statements best describe you? (check all that apply)
How would you describe the role of faith in your life and leadership? (select the best description)

Other
How often do you meet one-on-one with your CEO? (select the best description)

Other
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New Key Player Application