LEAD Derby Application

Apply to be a participant in the 2020 LEAD Derby class!

First Name

Last Name

Address Line 1

Address Line 2

City

Zip/Postal Code

Phone

Cell Phone

Present Employer (if employed outside the home)

Job Title

Work Address

Address Line 1

Address Line 2

City

Zip/Postal Code

Preferred email address for LEAD Derby communication

I am aware of the time requirements for LEAD Derby and will attend all scheduled sessions.

Yes No

My employer has approved my absence from work as required by the Lead Derby program.

Yes No

Today's Date:

Format: M/d/yyyy

Upon submission, Mark Staats will email you to you confirm your application. If you do not receive an email within 24 hours, please re-submit your application or contact the Chamber at (316) 788-3421 or mark@derbychamber.com