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Emerging Leaders Academy

Registration Agreement for the Class of 2015 Year 1

To register on-line, fill out the form below. If you prefer to email or fax a form, you can also download a form.

Contact Information
Participant Name
Required
Preferred Name (i.e., Bill instead of William, etc.)

Firm
Required
Title / Position
Required
E-mail Address
RequiredInvalid Format
Address1
Required
Address 2

City / State or Province
Required Required
Zip / Country (XXXXX-XXXX)
Required
Phone (XXX-XXX-XXXX)
RequiredInvalid Format
Web Site (www.mycompany.com)
Required

Biographical Information for the Participant Binder
Brief Bio (under 50 words) or fill in the fields below and Upstream staff will create a bio based on your information. This bio will be used in the participant binder available to all Emerging Leaders Academy participants.

Areas of Technical Expertise

Industry Specialties

College Alma Mater

Year You Began Public Practice

Hobbies / Interests / Little Known Facts

Firm Contacts

If you do not yet have a guide and/or advocate, please leave these areas blank and inform Upstream when these individuals has been identified. The first guide call will be held in July, so please be sure to provide Upstream with contact information for your guide and advocate by this date.
Guide position description.
Advocate position description.

Guide Name

Guide Email
Invalid Format
Guide Title

Guide Address (if different than participant address)

Advocate Name

Advocate Email
Invalid Format
Advocate Title

Advocate Address (if different than participant address)


Event Preference

Please choose one. This will serve as your registration to the event. Which UA event should I attend?
HeadWaters Leadership Conference 2012 • July 12-13, 2012 • Denver, Colorado
BluePrint for Excellence • July 23-24, 2012 • Park City, Utah
Emerging Leaders Conference Fall 2012 • September 27-28, 2012 • San Antonio, Texas*
BestPractices Conference 2012 • October 25-26, 2012 • Chicago, Illinois
Emerging Leaders Conference Winter 2013 • January 3-4, 2013 • Scottsdale, Arizona*
None/Undecided - Please let us know your preference by June 15, 2012

*Year One participants are encouraged to attend one of the two Emerging Leaders ConferencesRequired


Photo
Photo to be used in the participant binder. Your head and shoulders photo should be printable at a minimum of 2 X 2.75 inches (we will crop as necessary). If you are not able to attach a photo to this application, please email one to georgiac@upstreamacademy.com by June 1.

Pricing Information
UAN Member: Three Annual Payments of $2,500
Non-UAN Member: Three Annual Payments of $3,000 Required


Payment Information
Check to follow - please mail to P. O. Box 1147, Helena, MT 59624 with a copy of this registration
Pay by MasterCard or Visa Required (After sumitting this form, you will be redirected to a secure site to enter your credit card information)


I have read and agreed to the Emerging Leaders Commitment Required