Registration - P-LDS

Public Leadership Development Series Registration

Kenosha | Fall 2025 | Launch Date October 2, 2025
Location:

Kenosha Area Business Alliance
5500 6th Avenue, Suite 200
Kenosha, WI 53140

Time:
The first workshop is 4-1/2 hours in length: 8:00 a.m. - 12:30 p.m. Remaining workshops are 4 hours: 8:00 a.m. - 12:00 p.m.

Cost:
$530* per month | per person
covers materials, coaching sessions and workshops

*Paid in full price, prior to any discount is $6,350

Add standard group discounts** for multiple enrollments:
- Register three leaders and receive 10% off each registration
- Register four leaders and receive 15% off each registration
- Register five leaders and receive 20% off each registration
**Group discount is applied after earlybird discount has been applied
Manager's Information
Participant #1 - Manager's Name*

First NameLast Name
Participant #1 - Manager's Title*
Participant #1 - Manager's Email*
example@example.com
Participant #1 - Manager's Phone Number*
Please enter a valid phone number.
Participant Information
Participant #1 - Name*

First NameLast Name
Participant #1 - Preferred First Name (If different from above)
Participant #1 - Title*
Participant #1 - Email*
example@example.com
Participant #1 - Company Name*
Participant #1 - Company Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Participant #1 - Company Phone Number*
Please enter a valid phone number.
Participant #1 - Mobile Phone Number*
Please enter a valid phone number.
Cost Per Person
Would you like to register a second person in your company?

Yes
Participant #2 - Name

First NameLast Name
Participant #2 - Preferred First Name (If different from above)
Participant #2 - Title
Participant #2 - Email
example@example.com
Participant #2 - Mobile Phone Number
Please enter a valid phone number.
Participant #2 - Company Phone Number*
Please enter a valid phone number.
Does participant #2 have a DIFFERENT manager than participant #1?

YesNo, it is the same manager listed above.
Participant #2 - Manager Name

First NameLast Name
Participant #2 - Manager Title
Participant #2 - Manager Email
example@example.com
Participant #2 - Manager Phone
Please enter a valid phone number.
Cost Per Person
Would you like to register a third person in your company?

Yes
Participant #3 - Name

First NameLast Name
Participant #3 - Preferred First Name (If different from above)
Participant #3 - Title
Participant #3 - Email
example@example.com
Participant #3 - Mobile Phone Number
Please enter a valid phone number.
Participant #3 - Company Phone Number*
Please enter a valid phone number.
Does participant #3 have a DIFFERENT manager than participant #1?

YesNo, it is the same manager listed above.
Participant #3 - Manager Name

First NameLast Name
Participant #3 - Manager Title
Participant #3 - Manager Email
example@example.com
Participant #3 - Manager Phone
Please enter a valid phone number.
Cost Per Person
Would you like to register a fourth person in your company?

Yes
Participant #4 - Name

First NameLast Name
Participant #4 - Preferred First Name (If different from above)
Participant #4 - Title
Participant #4 - Email
example@example.com
Participant #4 - Mobile Phone Number
Please enter a valid phone number.
Participant #4 - Company Phone Number
Please enter a valid phone number.
Does participant #4 have a DIFFERENT manager than participant #1?

YesNo, it is the same manager listed above.
Participant #4 - Manager Name

First NameLast Name
Participant #4 - Manager Title
Participant #4 - Manager Email
example@example.com
Participant #4 - Manager Phone
Please enter a valid phone number.
Cost Per Person
Would you like to register a fifth person in your company?

Yes
Participant #5 - Name

First NameLast Name
Participant #5 - Preferred First Name (If different from above)
Participant #5 - Title
Participant #5 - Email
example@example.com
Participant #5 - Mobile Phone Number
Please enter a valid phone number.
Participant #5 - Company Phone Number
Please enter a valid phone number.
Does participant #5 have a DIFFERENT manager than participant #1?

YesNo, it is the same manager listed above.
Participant #5 - Manager Name

First NameLast Name
Participant #5 - Manager Title
Participant #5 - Manager Email
example@example.com
Participant #5 - Manager Phone
Please enter a valid phone number.
Cost Per Person
Registration Information, Terms, & Conditions
Please read the Public Series Registration Information Terms and Conditions and select yes below confirming your agreement. I've read and agree with the terms outlined in the Open Enrollment Registration Information, Terms and Conditions*

Yes
Please confirm you (or the individual you are registering) has formal direct reports. If no direct reports, consider enrolling in our Emerging Leader Series. If you feel your situation falls in a gray area, you are welcome to have discussion with Theresa Custer by contacting her at tcuster@livingasaleader.com).*

Yes
Billing Information
Billing Attention / Accounts Payable Contact*

First NameLast Name
Billing Attention / Accounts Payable Contact Email*
example@example.com
Billing Attention / Accounts Payable Contact Phone Number*
Please enter a valid phone number.
Billing Address is the same as the company address noted above?*

YesNo
Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Payment Terms*
Estimated cost prior to discounts:
DISCOUNT FOR THREE =
DISCOUNT FOR FOUR =
DISCOUNT FOR FIVE =
Total cost for one =
USD $
Total cost for two =
USD $
Total cost for three =
USD $
Total cost for four =
USD $
Total cost for five =
USD $
Additional Billing Information
Additional Details
Who referred you?
Should be Empty:

Public Leadership Development Series Registration

Manager's Information

Participant Information

Registration Information, Terms, & Conditions

Billing Information

Additional Details