2024 - 2025 Leadership Pampa Registration Form

Participant Name*

First NameLast Name

Preferred Name

Gender

Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Preferred Email*

example@example.com

Phone Number*

How many years have you been in Pampa?*

Shirt Size*

How did you learn about Leadership Pampa?

Do you have any dietary restrictions?

Name of Business*

Title/Position*

Name of Supervisor*

First NameLast Name

Physical Address of Business*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Is the business mailing address the same as the business physical address?*

YesNo

Business Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Business Phone Number*

Please enter a valid phone number.

How long have you worked here?*

Background: Briefly summarize your personal background. List degrees/certificates received, dates, field of study, vocational training programs, professional institutes, etc. List extra-curricular activities and special honors received. *

The Leadership Pampa program will begin in August with orientation and continue with regularly scheduled classes from August through April. To graduate from Leadership Pampa, each participant is required to attend an orientation session and nine one-day training sessions. No more than one absence is allowed. Participants must attend all portions of a session to receive credit for the session. Tuition will not be refunded if the participant does not complete the program.

Tuition for each participant is $600.00

Will you be able to fulfill this commitment?*

YesNo

Tuition will be paid by:*

ParticipantEmployer/sponsor

This candidate has my full support to participate in Leadership Pampa. I am aware of the time commitment involved in his/her effective participation, as well as the financial obligation. I also understand that if this individual is selected and is unable to complete the program, or changes employment, no portion of the tuition will be refunded.

Signature*

Corporation/Organization*

Title*

Date*

Date

I understand the purpose and commitment of the Leadership Pampa program, and if I become a participant, I will devote the required time. I understand and accept the requirements regarding time, attendance, attending one board meeting (County or City Commission meeting, EDC Board, or PISD Board), and Tuition, and I realize there may be other requirements. I have discussed my participation in the Leadership Pampa program with my employer, and I have my employer's support in participating in the program.

Signature*

Date*

Date

Would you like to add an additional participant?*

YesNo

Participant Name*

First NameLast Name

Preferred Name

Gender

Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Preferred Email*

example@example.com

Phone Number*

How many years have you been in Pampa?

Shirt Size*

How did you learn about Leadership Pampa?

Do you have any dietary restrictions?

Is the present employment information the same as the previous applicant?

YesNo

Name of Business*

Title/Position*

Name of Supervisor*

First NameLast Name

Physical Address of Business*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Is the business mailing address the same as the business physical address?*

YesNo

Business Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Business Phone Number*

Please enter a valid phone number.

How long have you worked here?*

Background: Briefly summarize your personal background. List degrees/certificates received, dates, field of study, vocational training programs, professional institutes, etc. List extra-curricular activities and special honors received. *

The Leadership Pampa program will begin August 23rd, 2023, with orientation and continue with regularly scheduled classes from September 2023 through May 2024. To graduate from Leadership Pampa, each participant is required to attend an orientation session and nine 1-day long training sessions. No more than one absence is allowed. Participants must attend all portions of a session in order to receive credit for the session. Tuition will not be refunded if the participant does not complete the program.

Tuition for each participant is $600.00

Will you be able to fulfill this commitment?*

YesNo

Tuition will be paid by:*

ParticipantEmployer/sponsor

This candidate has my full support to participate in Leadership Pampa. I am aware of the time commitment involved in his/her effective participation, as well as the financial obligation. I also understand that if this individual is selected and is unable to complete the program, or changes employment, no portion of the tuition will be refunded.

Signature*

Corporation/Organization*

Title*

Date*

Date

I understand the purpose and commitment of the Leadership Pampa program, and if I become a participant, I will devote the required time. I understand and accept the requirements regarding time, attendance, attending one board meeting (County or City Commission meeting, EDC Board, or PISD Board), and Tuition, and I realize there may be other requirements. I have discussed my participation in the Leadership Pampa program with my employer, and I have my employer's support in participating in the program.

Signature*

Date*

Date

We have two available sponsorships for Leadership Pampa. If you would like to sponsor the event, as well as send students to the program, please pick a sponsorship.

Sponsorships

Catalyst Sponsorship - $1,250 and the promise of 1 participantTrailblazer Sponsorship - $2,500 and the promise of 2 participants

How would you like to pay?*

Credit or Debit CardCash or Check at time of event (Please make checks payable to "Leadership Pampa")Invoice me

2023-2024 Leadership Pampa Program

$600.00 Quantity

Catalyst Sponsorship$1,250 and the promise of 1 participant

$1,250.00 Quantity

Trailblazer Sposorship$2,500 and the promise of 2 participants

$2,500.00 Quantity

Total

$0.00

Credit Card

Leadership Pampa 2024 - 2025

Present Employment

Commitment

Employer/Sponsoring Organization

Applicant

Present Employment

Commitment

Employer/Sponsoring Organization

Applicant

Sponsorships

Credit Card