COURSE QUESTIONNAIRE June 14/17, 2018

Welcome to Leadership in Action One!

Here is the Questionnaire for your course. Please answer the questions and hit submit to send your responses to Arise Culture & People. Your responses will only be read by the staff of your course. We ask that you fill in the Questionnaire as soon as possible. Each answer is limited to 250 words - about half a page.
Please Note: After submitting the questionnaire, you will not have access to your responses. If you would like to keep a record of your answers, it is suggested that you prepare/store your answers in a separate document prior to submission.

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* 1. Preferred Name:
(This name will appear on your Name Badge)

First/Last Name

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* 2. Preferred Email:

Email Address:

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* 3. Preferred Telephone Number:

Phone Number:

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* 4. Are you a member of ICF pursuing credit?

Yes

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* 5. Describe your current professional goals. (i.e., Job, career, income, contribution):

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* 6. Describe your current personal goals. (i.e., relationships, family, leisure time):

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* 7. What do you consider to be your strengths?:

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* 8. What do you consider to be your limitations?:

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* 9. Describe your predominant mood and how it shows up in your personal and professional life. (Examples include tense or relaxed, optimistic, pessimistic):

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* 10. What new story you are inventing for your life?:

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* 11. What do you speculate that this SI course can offer you in your personal and professional life? What do you want to accomplish in this course?:

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* 12. List known allergies:

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* 13. List medications you are taking for physical or psychological conditions:

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* 14. List any injuries we should be aware of:

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* 15. Are you a vegetarian?:

Yes

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* 16. Please list any food restrictions, intolerances or allergies:

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* 17. Name of Physician and Telephone Number:

Physician

Telephone Number:

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* 18. Emergency Contact Person, Relationship and Telephone Number:

Emergency Contact

Relationship

Question Title

* 1. Preferred Name:(This name will appear on your Name Badge)

Question Title

* 2. Preferred Email:

Question Title

* 3. Preferred Telephone Number:

Question Title

* 4. Are you a member of ICF pursuing credit?

Question Title

* 5. Describe your current professional goals. (i.e., Job, career, income, contribution):

Question Title

* 6. Describe your current personal goals. (i.e., relationships, family, leisure time):

Question Title

* 7. What do you consider to be your strengths?:

Question Title

* 8. What do you consider to be your limitations?:

Question Title

* 9. Describe your predominant mood and how it shows up in your personal and professional life. (Examples include tense or relaxed, optimistic, pessimistic):

Question Title

* 10. What new story you are inventing for your life?:

Question Title

* 11. What do you speculate that this SI course can offer you in your personal and professional life? What do you want to accomplish in this course?:

Question Title

* 12. List known allergies:

Question Title

* 13. List medications you are taking for physical or psychological conditions:

Question Title

* 14. List any injuries we should be aware of:

Question Title

* 15. Are you a vegetarian?:

Question Title

* 16. Please list any food restrictions, intolerances or allergies:

Question Title

* 17. Name of Physician and Telephone Number:

Question Title

* 18. Emergency Contact Person, Relationship and Telephone Number:

* 1. Preferred Name:
(This name will appear on your Name Badge)