The Self-Aware Leader Registration Form

Please complete each section below to secure your seat. Important: each participant is required to register. Please use this URL if you need to send this registration form to a participant to complete.

Contact Information

First Name *

Last Name

Title *

Company *

Email Address *

Preferred Mailing Address *

I already have a copy of The Self-Aware Leader book and do not need a copy.Yes, I do have a copy.No, I don’t have a copy. Please send one.

Time Zone *

Scheduling & PreferencesThe program includes a “coaching circle” with a smaller group follows each main module to help the partcipants apply what they are learning. Participants will be with the same coaching circle for the entirety of the program to help build community. We also offer the option to include your manager on program communications so they can be aware of what you are learning and support you in your leadership journey. This is recommended but not required.

Please indicate your first choice for the monthly 1-hour coaching circles *

Please indicate your second choice for the monthly 1-hour coaching circles *

Manager's Name

Manager's Email

Include Manager on all pre-/post-communications for four program modules?

Referral

How did you learn about this program?

Other referral

Signature *

By signing this agreement, I acknowledge one (1) registration for The Self-Aware Leader 2025 Virtual Leadership Program. This registration is nonrefundable. Transferring participation from one individual to another must take place before 30 days prior to program start date. Full payment is due before 30 days prior to the program start day. Leadership content learned in this program may be applied to assist in the development of the program participant. This agreement, and participation in the program, does not, however, constitute a license to copy, reproduce, transmit or distribute in any way or sell or otherwise commercially exploit program content without the specific written permission of Gallagher Leadership. Permission to use program content for such other commercial purposes is prohibited.

The Self-Aware Leader Registration Form

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