Clone of Confident Leaders Program Application Form

The 'Reconnect' Series - Gippsland 2026

Registration Form
Commencing Feb / Mar 2026

Dates and Venues to be finalised
Name:*

First NameLast Name
Preferred name
Details*

Address

Address 2

TownState

Post Code
E-mail*
example@example.com
Phone Number*
Desired outcome from the program?*
Greatest current challenge?*
How did you hear about the program?
Is there any reason you are unable to commit to participating in the full 6 months of the program, in person?*

YESNO
If YES, please provide more information
Do you have any dietary restrictions? (eg allergies)*
Do you have any special requirements? (eg disability)*
To help with venue planning, which town will you be travelling from?*
Program cost*

I am aware the cost of the program is $2,900 +GST, and commit to paying this amount in full, prior to the commencement of the program (unless otherwise negotiated).
Please only submit this form if you agree to:
- Fully participating in the program
- Attending all workshops in person
- Participating with respect and kindness toward other particpants
- Commit to maintaining the confidentiality of others and what is shared within the group
Should be Empty:

The 'Reconnect' Series - Gippsland 2026