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2023 - 2024 RDLI Application Form

Please fill out all fields below.

Name Block - Simple

First Name

Last Name

Preferred Name

Home Address

Address Line 1

Address Line 2

City

Zip/Postal Code

Contact Phone Number

Employer

Employer Address

Address Line 1

Address Line 2

City

Zip/Postal Code

Sponsoring Business or Organization (If Applicable)

Allergies and/or Dietary Requirements

Please contact me to discuss accomodations needed to participate in the RDLI Program

Yes, Contact Me

What is your definition of leadership?

Tuition: Cost of the RDLI Program is $850. Check should be made payable to the Mt. Pleasant Area Chamber of Commerce. You will NOT be permitted to attend the first class if your scheduled payments have not been received. Tuition will be paid by:

Me My Employer My Sponsor

Employer/Sponsor Name & Title

*By Signing here, you consent that all of the above information is correct and true.

Name of Applicant

*By signing here, you consent that all of the above information is correct and true.

Date

Format: M/d/yyyy