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Application for LeadWell
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* Indicates required question
First Name
*
Your answer
Last Name
*
Your answer
Title
*
Your answer
Organization
*
Your answer
Phone Number
*
Your answer
Email
*
Your answer
Are you a leader with direct reports?
*
Yes
No
If yes, how many direct reports do you have?
Choose
1-5
5-10
10-15
15+
Are you interested in signing up for yourself or for multiple leaders at your organization?
*
Myself
I'm interesting in doing this program with senior leaders at my organization
Would you be the primary decision maker regarding participating in this program?
*
Yes, I'm able to give final approval
No, but I have significant influence
No, my boss needs to approve it
Why are you interested in LeadWell? What outcomes do you hope to achieve?
*
Your answer
When would you be interested in starting this program?
*
next 1-3 months
next 4-6 months
next 6-12 months
Any other information you'd like to share?
Your answer
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