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Townsend Leadership Program Questionnaire

We appreciate your interest in becoming a member of a Townsend Leadership Program. Please fill out the following questions to help TLP Director, Elaine Morris, get to know you, your leadership role, your background and your goals.

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* 1. Contact Information at Your Organization:

Name: *

Title/Role: *

Company: *

Address: *

City/Town: *

State: *

ZIP: *

Email Address: *

Direct Line: *

Extension:

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* 2. Contact Information at Your Home

Address:

City/Town:

State:

ZIP:

Email Address:

Main Number:

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* 3. I prefer to be contacted at this phone number:

Direct Line (Business)

Cell Phone

Home Phone

Other (please specify)

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* 4. I prefer any TLP correspondence and newsletters to be sent to this email address:

Work Email

Home Email

Other (please specify)

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* 5. If accepted as a TLP Member, you will be added to Elaine's monthly blog that contains relevant information on TLP, leadership articles and up-coming events.

I have read that I will be added to the mailing list and understand that I may opt out at any point in time.

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* 6. Birthday

Birthday

Date

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* 7. Marital Status:

Married

Single

Other (please specify)

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* 8. If married, name of spouse:

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* 9. Wedding Anniversary (if applicable):

Wedding Anniversary

Date

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* 10. If applicable, name of significant other:

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* 11. Kid(s) name and ages:

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* 12. Pets:

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* 13. Church/Worship if any:

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* 14. How did you hear about the TLP?

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* 15. What other leadership and/or growth programs have you attended?

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* 16. Are you being sponsored by your organization?

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* 17. Have you worked with a therapist and/or a coach in the past or currently? Please explain.

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20% of survey complete.