First Name:*

Last Name:*

Email:*

Alternate Email:

Phone Numbers: (Leave blank if you prefer not to be contacted at this number.)

Home:

Work:

Cell:

Home Address:

City:

State:

Zip:

Emergency
Contact' Name:

Emergency
Contact's Phone:

Do you require any special accommodations? (Linguistic, dietary, physical, religious) YesNo

If yes, list:

Type of Work
or Industry:

Name of Business or Organization:

Organization's
Address:

City:

State:

Zip:

Job Title:

Number of reporting relationships between you and the senior officer:

Number of employees in the business or organization:

Do you consider yourself: (choose one) Young Professional Mid-career Senior Executive?

Is your employer aware and supportive of the time and monetary resources required to participate in Leadership for Life?

Yes No

List three other leadership roles you have held that reflect your leadership capacity:

1

2

3

What is the highest level of education you have attained?

What were your main fields of study?

What formal religious or theological training have you completed?

Declared Faith Tradition:

Identify the three primary aspects of your life that best demonstrate your faith or values commitment:

1

2

3

What prior leadership training, courses, or sources have you utilized?

List the community, civic, business, religious, professional, or social organizations which you serve that best demonstrate your life values and note in in what capacity you serve them:

Personal Attributes(Please rate each of the following on a scale from 1 to 5 with one being very low and five being very high.)

Comfort interacting with members of different denominations: 1 2 3 4 5

Comfort of participating in theological or scriptural discussions: 1 2 3 4 5

Comfort sharing personally in small group settings: 1 2 3 4 5

Comfort speaking publicly in larger group settings: 1 2 3 4 5

Desire to know and respond to God more deeply and live out one’s faith more fully: 1 2 3 4 5

Desire to have a spiritual influence in your daily environment and local community: 1 2 3 4 5

List your top three challenges as a leader which you hope to address through LFL:

1

2

3

Program fees are $2500 per person and include all retreat and material costs for the year.
To ensure program fees are covered, we ask you to identify the responsible party so we can confirm with them prior to acceptance.

Check one:*

I will be personally responsible for ensuring all program fees are covered.

My employer or the person listed below will ensure all program fees for my participation are covered.

Name and title of sponsoring party:

Email address of sponsoring party:

Phone number of sponsoring party:

I would like to apply for partial program fee support in the amount of: $

By submission of this application, I accept the terms of Leadership for Life including attendance, funding, and participation.