Member Information Form

User Name
your user name is your telephone number with no hyphens, parentheses, or other characters

  0000000000

Password
minimum of 8 characters/numbers

Membership Level
 

  Please select ... Professional Individual Leadership Program under $125,000 Leadership Program over $125,000 Association/Academic/Institutional For Profit, Corporate, Business

1. Professional/Individual - $150

2. Leadership Program - $250

    Programs with budgets under $125,000

3. Leadership Program - $350

    Programs with budgets over $125,000

4. Association/Academic/Institutional - $450

5. For Profit, Corporate, Business - $550

Program/Company Name

Parent Organization
(if applicable)

Affiliation Type

  Please select ... Independent Chamber College or University For Profit or Corporation Other

Year Established

Address

City, State, Zip

Phone (use hyphens)

  000-000-0000

Fax (use hyphens)

  000-000-0000

Website (include http://)

Main Contact Person

Title

Email

Executive Director
(if not main contact person)

Coordinator/Administrator
(if not main contact person)

Program Mission

Program Description

Program(s) Offered
(check all that apply)

Youth
Adult
Seniors
Young Professional
Alumni
Executive
Other:

Area Served
(not applicable is an option)

Geographic range:
  Please select ... city county multi-city region multi-county region state national international not applicable

Geographic profile:
  Please select ... urban rural suburban all not applicable

Population of area served:
  Please select ... less than 10,000 10,000-25,000 25,000-50,000 50,000-100,000 100,000-200,000 200,000-500,000 more than 500,000 not applicable

Description of area served:

Size of Your Program
(not applicable is an option)

Budget range:
  Please select ... less than $5,000 $5,000-$10,000 $10,000-$20,000 $20,000-$40,000 $40,000-$60,000 $60,000-$80,000 $80,000-$100,000 $100,000-$150,000 $150,000-$200,000 $200,000-$300,000 more than $300,000 not applicable

Average class size:
  Please select ... less than 20 20-30 30-40 40-50 more than 50 not applicable

Tuition fees:
  Please select ... Free less than $500 $500-$750 $750-$1,000 $1,000-$1,500 $1,500-$2,000 $2,000-$2,500 $2,500-$3,500 $3,500-$5,000 more than $5,000 not applicable

Do you post your class curriculum on your website?

No Yes  if yes, please provide the web address, including http://)\
URL:   

Do your classes do a class project? 

No Yes  if yes, please describe

Alumni
(not applicable is an option)

What is the size of your alumni group?     Please select ... less than 100 100-250 250-500 more than 500 not applicable
How many alumni activities do you host each year?      Please select ... 0 1-3 4-6 6-9 9-12 more than 12 not applicable

Other information you would like to share with your peers:

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