Leadership Engage Application

The two day class will be scheduled as enough approved applications are received. You will be notified of the proposed dates well in advance for planning. Program cost is $85 (subject to change) and covers transportation, meals and supplies needed for the days. Payment for the class must be made at least 10 business days prior to the class and received at the Roane Chamber, 1209 N. Kentucky St., Kingston, Tn. 37763.

Name*

First NameLast Name

Personal Email*

example@example.com

Cell Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Nominee Position / Occupation:*

Work Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Work Email*

example@example.com

No RestrictionsVegetarianGluten-FreeOther

Please list any physical restrictions: (moderate amount of walking will be required)*

YesNo

How long have you resided in the area?*

What do you expect to gain from this program?*

How did you hear about Leadership Engage?*

YesNo

By signing and submitting this form, I hereby release, indemnify, and hold harmless the Roane Alliance, their agents or any individuals involved in the planning, organization or presentation of Leadership Engage for any accident, injury, illness, or damage whatsoever related to the above-mentioned participant in any activity or session of Leadership Engage.

Signature*