Applicant Acceptance Form

Congratulations on being accepted into the 2021 Class! Please fill out the form below by December 18, 2020.

Mark your calendars for the Welcome Reception at Seneca One Tower (January 7 for CE, and January 14 for RL)!

First Name        Last Name        Fleece Size    
1. Do you have any changes to the contact information listed on the class list? If so, please use comment box to update.
2. Each Class member will receive a name tag for day sessions and events. How would you like your first and last name to appear on your name tag?
3. Do you have any food allergies or special dietary restrictions. If so, please check all that apply:
If other, please explain:
4. Please indicate your meal selection for dinner at the Opening Retreat (select one):
5. Do you have any physical limitations that will require special accommodation at the retreat location, or at other LB activities? Please specify in comments.
6. Please upload your headshot here. This will be used in your class "year book" distributed at the opening retreat.
File Size : No Larger Than 3 MB
7. Please list an emergency contact.
Name        Relationship        Phone    
Leadership Buffalo, Inc. has my full permission to use photographs, slides, video, other media, etc., taken during any Leadership Buffalo function for publication/promotion by Leadership Buffalo.
I agree with the statement above

This release is being executed by me in connection with and in consideration of my participation in Leadership Buffalo. I am aware that Leadership Buffalo, Inc. is a not-for-profit corporation providing valuable local experiences to current and/or potential leaders in the Western New York area. I understand I may be asked to participate in a variety of activities in connection with Leadership Buffalo such as, but not limited to, tours of prisons, plants, construction sites, social agencies, and other public and private facilities. I also understand that in the course of any such activity, I could experience or incur personal injury or death or damage to my property. I voluntarily assume all risk of such injury, death and damage and hereby release Leadership Buffalo, Inc. from all claims which I may have or acquire related thereto.

I will comply with all instructions, rules and regulations of Leadership Buffalo while I am participating in any Leadership Buffalo program or event.

This agreement shall inure to the benefit of Leadership Buffalo, Inc. and shall be binding on myself, my heirs, executors, legal representatives, administrators and assigns.

I agree with the statement above

I consent to receive text messages to the mobile number provided. Consent is not a condition of purchase. Standard message and data rates may apply. Message frequency depends on account settings. At anytime you can text to 71441 the word HELP to get more information or STOP to no longer receiving messages.
  
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