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Third Age Initiative^™

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CLASS 18 REGISTRATION

Participant Information:

First Name *

Last Name *

Email *

Street Address

City *

State/Province *

Zip *

Home Phone *

Retired *

Previous Company Information (if applicable):

Prior Company Name *

Prior Title *

Additional Information:

Do you have access to a computer? *

Yes
No

Do you have access to wifi? *

Yes
No

What kind of technology do you have access to? *

Please tell us about community, civic, professional , business, religious, social and other organizations of which you are or have been a member. Please also tell us about any responsibilities you have held in those organizations. *

Please tell us about your employment history and careers you have pursued. You need not tell us about all jobs over your entire lifetime, but tell us whatever will help us know about your interests and experience. *

What would you like to gain from the program, and what do you believe you can contribute by becoming part of this community leadership development program? *

LGH will hold some activities related to the Third Age Initiative using technology and virtual experiences. To help us plan and to help us help you prepare to get the most from these virtual experiences, please answer the following questions:

Do you regularly use email? *

Are you familiar with Zoom or other virtual meeting platforms? *

Very Familiar
Somewhat Familiar
No

Demographic Information:

**All of the following demographic questions are optional, but are extremely valuable in helping us to better understand the audiences we serve. Thank you for providing the data you are comfortable sharing and know that all demographic information will be kept confidential.

Birth Date *

// (mm/dd/yyyy)

Gender Identity *

Marital Status *

Race/Ethnicity *

Income *

<$16,500
$16,501 - 22,500
$22,501 - 50,000
$50,001 - 75,000
$75,001 - 100,000
Over $100,000
Unknown

Education *

< High School
Associate Deg (2yrs)
Bachelors Deg (4yrs)
High School
Masters Deg (Grad)
PhD (Doctorate)
Post Graduate Work
Professional Degree
Some College
Some Grad Work
Some Post Grad Work
Some Secondary Edu
Unknown

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Contact us

1049 Asylum Avenue
Hartford, CT 06105
info@leadershipgh.org
860.951.6161

Our programs

Executive Orientation
Leaders on Board
Quest
Third Age Initiative^™
Consulting and Training

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Leadership development

Who we serve

Who we are

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