I'm so glad you're here.

Thank you for taking this step. Choosing to invest in your own leadership is one of the most important decisions you can make—not just for yourself, but for the people and communities you serve. I’m honored you’re considering joining this remarkable group of women.

-Heather Hankamer, Executive Director

Signature Program Registration

Basic Information

First name

Last name

Phone

Emergency Contact

Emergency Contact Phone

Relationship to self

How did you hear about CCC?

Career Information

Employer Name

Current Title

In what industry do you work?

How long have you been in your current role?

How many, if any, people do you lead?

Briefly describe your role and responsibilities

What challenges are you currently facing in your work?

Tell us a little about your professional life

How do you spend your personal time (hobbies, family, travel, etc.)

How would you describe the phase of life you are currently in?

How would you describe your overall health?

What drew you to this program?

What is your current or past experience working with an executive coach?

Please use this space to share any other information you feel is important

Demographics

Note: We collect this data to use in our grants and scholarship funds requests.

Are you of Hispanic, Latino, or of Spanish origin?

Yes

Proprietary Information Agreement

The CCC Leadership Program for Women (“Program”) is a six-month leadership program developed in partnership with Marsha Clark & Associates. The Program and its materials, content, design, and structure (“Program Assets”) are the property of Marsha Clark & Associates, and are protected by copyright and/or various other laws. The use of any Program Assets without the express permission of Marsha Clark & Associates is strictly prohibited.

As part of the consideration for you being allowed to participate in Program, you agree to only use the Program Assets disclosed to you during or after the Program for your own personal use, and to forever maintain the confidentiality of those Program Assets. This does not mean that you cannot use the skills that you learn from the Program in your daily life. Nor does it mean that you cannot talk to others about the Program in general. Rather, it means that you agree not to do anything that could compromise the Program, the Program Assets, or their value. For example, you may not: (1) record the Program, in whole or in part; (2) repeat to others in detail any of the presentations or discussions made during the course of the Program; (3) share, sell, give away, copy, distribute, or publish any Program materials provided to you, or allow others to do the same; or (4) use any of the Program Assets to develop or improve, or help others develop or improve, a competing program. Your acceptance of this Agreement is a condition to your being allowed to participate in the Program.

By accepting this Agreement, you acknowledge that you have read and understand the foregoing terms and agree to be bound by them.

Reference Release Agreement

The CCC Leadership program is a comprehensive program designed and developed by Marsha Clark & Associates to inspire women to explore, discover, and fulfill their potential. A valuable aspect of the program is to have the capability to reference women who have participated in the program as a means to help others become aware of the opportunities the program affords. To this end, CCC Leadership requests your permission to use your name as a reference for the program.

Use of your name as a reference will be limited by the criteria checked:(required)

CONVERSATIONAL REFERENCEABILITY (Permission to use my name as a program participant in conversations that CCC Leadership may have as part of efforts to introduce and describe the program to others.)

PRINTED REFERENCEABILITY (Permission to use my name as a program participant in written materials created by CCC Leadership as part of efforts to introduce and describe the program to others.)

QUOTED REFERENCEABILITY (Permission to use a specific quote from me, along with my name, in verbal or written material created by CCC Leadership as part of efforts to introduce and describe the program to others.

Any quote attributed to me will be reviewed and signed off by me on a separate agreement before it is used in any manner.)

By signing this Agreement, you affirm that you give CCC Leadership permission to use your name as a reference for the CCC Leadership Program in the manner you have noted by marking the above listed options.

Counseling Acknowledgment Agreement

The CCC Leadership program is a comprehensive program designed and developed by Marsha Clark & Associates. As you make this journey, you may experience situations that evoke emotions, thoughts, and feelings. As a participant, you must take full responsibility for self-screening if such situations are a concern.

This program was not designed or developed to be, or should ever be construed to be, a substitute for counseling or psychotherapy. If you are currently participating in a counseling or psychotherapy program, you should discuss your participation in this program with the counselor or therapist, and should not participate without joint concurrence between you and your counselor or therapist.

By signing this Agreement, you affirm the following: 1) Understand that participation in this program may create situations that evoke emotions, thoughts, and feelings, 2) Have made an informed and voluntary decision that participation is appropriate for you, 3) Take full responsibility for your decision to attend, and 4) Take full responsibility for any transformations that you experience as a participant in this program.

Signature

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