Palmetto Leadership Chester County Class of 2012

Palmetto Leadership Chester County Registration Form

Name:
Address:
City:	State: Zip Code:
Telephone:
Email:
Employer:
In the space provided, please tell us about any additional aspects of your background, community involvement or professional achievements that you would like to share.
Statements of Participation and Photo Release Please check each statement to signify your agreement. Yes, my employer supports my time commitment to this program, including full attendance throughout the entire program schedule. Except for circumstances beyond my control I will complete the program in its entirety. I acknowledge that I am only allowed two (2) absences. Palmetto Leadership Chester County may dismiss me from the program if my performance proves unsatisfactory due to lack of interest or ability, unsatisfactory attendance (more than 2 absences), progress or conduct, violation of confidences shared during the program, or for any reason deemed by Palmetto Leadership Chester County to be detrimental to the overall program. Yes, my image can be used for Palmetto Leadership marketing purposes.
Some meals/snacks will be provided throughout the class term. Please note any unique dietary needs:
To submit this form, please enter the characters you see in the image:
	You will be redirected to our online store page where you need to add the "Palmetto Leadership Chester County 2012 Registration" to your cart for checkout and payment. If you would like to pay by check or cash press "Submit" and then send your $175.00 payment to: Clemson Extension 120 N. Congress Street, York, SC 29745. Scholarships are available.