Name*

First Last

Email*

Phone*

Address*

Street Address City State ZIP Code

Name of Company*

Company Address*

Street Address City State ZIP Code

Current Title*

How long have you held your current position?*

Have you been in a management position for at least 3 years?*

Yes
No

Please list your professional background.*

Please list your educational background.*

Please describe your management role and responsibilites.*

What is your biggest challenge in managing people?*

What is your interest in the program professionally?*

What is your interest in the program personally?*

In order of importance, please rate: • Self-growth •Networking •Development of Leadership Skills*

What is one of your PROFESSIONAL accomplishments of which you are most proud?*

What is one of your PERSONAL accomplishments of which you are most proud?*

What is the biggest challenge women face in Broward County today?*

Have you participated in any other Leadership Broward Foundation program?*

Yes
No

If you answer yes above, what program and class were you in?

How did you learn about Women Leading Broward?*

Please confirm that you will be able to attend the WLB Program Dates and Times below.*

Yes
No

Orientation January 13, 2025 – 4:30 p.m. – 6:30 p.m.
Session I – January 22, 2025
Session II – February 26, 2025
Session III – March 26, 2025
Session IV – April 23, 2025
Session V - May 21, 2025

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