Leadership Academy Enrollment Form

Get ready to enhance your leadership skills!

After completing this form you will be enrolled in the Leadership Academy. You will receive a confirmation email within 1-3 days. Upon successful completion of the course you will receive a digital badge credential.

Question Title

Which Leadership Academy do you want to attend?

Madison - 9/12-10/17, Thursday, 8 AM-4 PM

Fort Atkinson - 10/9-12/18, Every other Wednesday, 8 AM-4 PM

Question Title

Student Personal Information
(If student ID is unknown, enter N/A)

First Name

Last Name

Date of Birth

Email Address

Student ID # (if known)

Phone

Street Address

City

State

Zip

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Confirm your Email Address

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Please list any former names (this helps if you already have an account in the system).

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Name of your current workplace:

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By filling out this form you are agreeing to be billed and pay for Leadership Development Academy. Please note your bill will state "Leadership Academy" and "Leadership Academy part 2" for $325/each for a total of $650. You will receive your bill in the mail.

I understand.

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Select the ethnicity you most identify with (optional)

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Gender (optional)

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Are you paying for this class or is your employer?
If your employer is paying, please have them complete this form
Third Party Billing & Enrollment Authorization

I am paying

My employer is paying

Leadership Academy Enrollment Form

Get ready to enhance your leadership skills!

Question Title

Which Leadership Academy do you want to attend?

Question Title

Student Personal Information(If student ID is unknown, enter N/A)

Question Title

Confirm your Email Address

Question Title

Please list any former names (this helps if you already have an account in the system).

Question Title

Name of your current workplace:

Question Title

By filling out this form you are agreeing to be billed and pay for Leadership Development Academy. Please note your bill will state "Leadership Academy" and "Leadership Academy part 2" for $325/each for a total of $650. You will receive your bill in the mail.

Question Title

Select the ethnicity you most identify with (optional)

Question Title

Gender (optional)

Question Title

Are you paying for this class or is your employer?If your employer is paying, please have them complete this formThird Party Billing & Enrollment Authorization

Student Personal Information
(If student ID is unknown, enter N/A)

Are you paying for this class or is your employer?
If your employer is paying, please have them complete this form
Third Party Billing & Enrollment Authorization