Preliminary Participant Questionnaire

Date of 3 day Seminar *

First Name *

Last Name *

Agency:

Street Address *

Address Line 2

City *

State *

Zip Code *

Daytime Phone Number *

Email Address *

Emergency Contact: *

Phone *

Relation *

Position in the Community: *

Type *

Position in the Community:

Type

What are your Personal Strengths? *

What areas need strengthening? *

Are you responsible for supervising a Budget? *

How Much?

Are you responsible for finding funding for programs? *

Describe:

Describe any grants you have written or helped write. *

Why are you coming to the Circle of 10 Seminar? *

Existing Programs needing funding? *

Please Indicate 4-6 categories you are interested in.
Number 1 as most important and 6 is the least.
No duplicates please.

Interest #1 * 🛈

Interest #2 *

Other:

Interest #3 *

Other:

Interest #4 *

Other:

Interest #5

Other:

Interest #6

Other:

Dreams? If money was not an issue, what do you wish would happen? *

Classes are limited to 10-15 participants. Please name an alternate if you are unable to attend.

Phone Number