Seminar Application Form

* An asterisk = required fields

   Special Accommodation Request?

Special accommodation description

   CRC Credits requested

General Information:

* Full Name (First, Middle Initial, and Last):

* Current Position Title:

* Vocational Rehabilitation Organization:

Work Address (Street, City, State, Zip):

* Work Phone (valid format is xxx-xxx-xxxx):

Home/Cell Phone (valid format is xxx-xxx-xxxx):

* E-mail:

Fax (valid format is xxx-xxx-xxxx):

* Prior Leadership Training

In the space provided below, please list the leadership courses and/or training programs that you have completed in the past 3 years. Include the title of the training program, where the program was offered, its duration, and whether a certificate or academic credit was awarded for participation.

* Essay

* Leadership Issues

Statement of Agreement (must match with name provided above)

By entering your name, you agree to attend all the following conditions:

1. I will attend all sessions of the Executive Leadership Seminar in Rehabilitation Administration.
2. I will actively participate in all exercises, team projects, and peer discussions.
3. I will participate in the Executive Coaching portion of the Seminar.
4. I have access to and feel comfortable using virtual media, teleconferencing, video platforms, email and the internet.
5. My organization will cover the costs for the Executive Leadership Seminar in Rehabilitation Administration.
6. My supervisor/Director supports my application.

Note: Signature must be entered identically as it is at the top of this application: Full Name (First Name, Middle Initial, and Last Name)

* Signed: