THE STUDENT LEADERSHIP CHALLENGE®
Interest Form
First Name *
Last Name *
Job Title / Position *
School / Organization *
Mailing Address *
City *
State *
Zip Code *
Country *
Email *
Telephone
Fax
Estimated number of participants? *
Estimated budget?
Preferred delivery location? *
Please Choose One
On-site (our location / school grounds)
Off-site (mutually agreed upon location)
Purchasing role? *
Please Select One
Decision-maker
Evaluator / Recommender
Influencer
Not Involved
Please select which program options your organization is interested in (check all that apply):
Student LPI® 360 Individual Reports
Student LPI® 360 Group Report(s)
Student LPI® 360 Reassessment Report(s) (1 extra administration)
Student LPI® 360 Reassessment Report(s) (2 extra administrations)
Student LPI® 360 Reassessment Report(s) (3 extra administrations)
Virtual Classroom
Graphic Facilitation
All of the Above
With this program, can you tell us what your desired goals, outcomes, and/or objectives are?
Please share anything else that may help us better understand your needs and/or current situation:
Desired start date / time frame for program?
How did you hear about us? *