Grounded Leadership Immersion: Registration Form

Culture of Belonging Immersion

Course Registration
Name

First NameLast Name
Which cohort are you registering for?
Birth Date

MonthDayYear
Mobile Number
Format: (000) 000-0000.
Please describe yourself, including any social identifiers that feel important for you to name. (i.e. age, race, ethnicity, gender, etc.)
Where are you located? (City or town, state, and time zone)
Please describe your leadership role and the organization where you work.
Do you have any particular needs or accommodations that would be helpful for me to know about?
What drew you to register for this course? What are you hoping to get out of the experience?
How did you find out about this course?
Payment
How would you like to pay for this course?

Culture of Belonging Immersion: Youth

Jan 5 - Feb 23, 2027

[EARLY BIRD RATE through Nov 30th, 2026]

$399.00 Quantity

Culture of Belonging Immersion: Adult

Mar 16 - Apr 27, 2027

[EARLY BIRD RATE through Feb 15, 2027]

$399.00 Quantity

Culture of Belonging: Youth [SUPPORTER LEVEL]

If you are financially able, please consider donating to the scholarship fund to support course access for others.

$549.00 Quantity

Culture of Belonging: Adult [SUPPORTER LEVEL]

If you are financially able, please consider donating to the scholarship fund to support course access for others.

$549.00 Quantity

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Total

Credit Card

ACH Bank Transfer