Encore Louisville Participation

ENCORE LOUISVILLE:

Encore Louisville Participation 2026

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Name

Please enter your name*

Prefix Dr.MissMr.Mrs.Ms.Prof.Rev. First Middle Last Suffix

Address

Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code

Email*

Please enter your preferred email address.

Enter Email Confirm Email

Is your email address provided a work email or personal email?*

PersonalWork

Is your address provided a work address or personal address?*

PersonalWork

Career Information

Employment status*

1. Employed (Not retired)

2. Retired and now self-employed

3. Retired or retiring this year - not working post-retirement

Your Company and Job Title (for publication)

PLEASE READ: Please indicate your preferred title and company for publication on our website, in press releases, and in the graduate directory. The company name you provide will also be used on your nametag when you attend Leadership Louisville Center events. In the case of those retired and now self-employed, you might enter "President" for your job title, and "Jones Consulting" for your company. If you are retired and not employed, please put "Retired" for your job title, and for company, specify how you'd like to be represented, for example, "Retired Healthcare Executive", or LG&E and KU Energy, Retired."

Current Job Title (for publication, if applicable, or enter "Retired")

Current Company (for publication, if applicable, or enter "Retired")

Commitment

Please check box to confirm:*

I understand that I will need to provide Aimee Jewell with an updated bio. paragraph if any changes have occurred. Any updates should be sent to AJewell@LeadershipLouisville.org

I understand.

Please check box to confirm:*

By submitting this form and accepting this spot in this program, I am obligated to financially support the Leadership Louisville Center in full by the date indicated on the invoice. I will pay the invoice within 30 days of receiving it and will reach out to Kelsey May with any questions at KMay@LeadershipLouisville.org. I am responsible for payment even if I fail to complete the program, withdraw from the program for any reason (including before the program begins) or am dismissed from the program. No financial donations will be refunded.

I understand.

Please check box to confirm:*

In consideration of my acceptance for participation in this program, I do for myself, my heirs, and personal representatives hereby and forever release Leadership Louisville Center, their officers, employees, affiliates, successors, and agents from any and all manner of actions, causes of action, debts, claims, demands, or liability for any harm or injury I may sustain arising out of or in any way connected with my participation of this program. I make this release freely, and I acknowledge and assume all risks which may arise out of or may be connected with my participation in this program.

I understand.

Please check box to confirm:*

The Leadership Louisville Center respects individual privacy and, therefore, must obtain a signed release form from any participant visibly recognizable in the photograph. Crowd scenes where no single person is the dominant feature are exempt. These rules govern photographs intended for use in any Leadership Louisville Center publication of a marketing or a public relations nature, such as newsletters, brochures, viewbooks, promotional items, or other materials. Releases also must be obtained for photographs used on the website. These rules are not in effect when photographs are taken of news events. I hereby grant the Leadership Louisville Center permission to interview me and/or to use my likeness in photograph(s)/video in any and all of its publications and in any and all other media, whether now known or hereafter existing, controlled by the Leadership Louisville Center, in perpetuity. I will make no monetary or other claim against the Leadership Louisville Center for the use of the interview and/or the photograph(s)/video.

I understand.

IMPORTANT - PLEASE READ!

After clicking the Submit button, it may take a few moments to process your application. Once your application is submitted successfully, you will see a confirmation message and receive an email within five minutes that contains all the information you submitted. If you have any problem with this application, contact Emalee Morley at emorley@leadershiplouisville.org.

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