1

First Name

 *

First Name

2

Last Name

 *

Last Name

3

Address

 *

Address

4

Phone Number

 *

Phone Numberext.

5

E-mail Address

 *

E-mail Address

6

Do you receive Town of Queen Creek Trash and Recycling Services?

 *

Do you receive Town of Queen Creek Trash and Recycling Services?

Yes

No

7

Do you currently serve in a volunteer capacity? (HOA Board, Town Commission, Nonprofit Volunteer, etc.)

 *

Do you currently serve in a volunteer capacity? (HOA Board, Town Commission, Nonprofit Volunteer, etc.)

Yes If other, type text here.

No

8

What do you think are the top three (3) issues facing Queen Creek today?

 *

What do you think are the top three (3) issues facing Queen Creek today?

What do you think are the top three (3) issues facing Queen Creek today?

What do you think are the top three (3) issues facing Queen Creek today?

What do you think are the top three (3) issues facing Queen Creek today?

9

How would you describe Queen Creek in three (3) words or sentences?

 *

How would you describe Queen Creek in three (3) words or sentences?

How would you describe Queen Creek in three (3) words or sentences?

How would you describe Queen Creek in three (3) words or sentences?

How would you describe Queen Creek in three (3) words or sentences?

10

What do you hope to gain from this class? What are your expectations for the program?

 *

What do you hope to gain from this class? What are your expectations for the program?

11

What type of industry do you work in? (if applicable)

What type of industry do you work in? (if applicable)

12

List your job title and company name (if applicable)

List your job title and company name (if applicable)

13

How did you hear about the CLI program?

How did you hear about the CLI program?

14

How many years have you lived in Queen Creek?

How many years have you lived in Queen Creek?

15

Please type how you would like your name printed on your CLI graduation certificate

 *

Please type how you would like your name printed on your CLI graduation certificate

16

What size polo shirt would you prefer? Please specify if you would prefer a mens or women's style polo (example: Men's Medium or Women's XXL).

 *

What size polo shirt would you prefer? Please specify if you would prefer a mens or women's style polo (example: Men's Medium or Women's XXL).

17

Please provide the phonetic spelling of your first and last name. This is how your name will be pronounced during the graduation ceremony.

 *

Please provide the phonetic spelling of your first and last name. This is how your name will be pronounced during the graduation ceremony.

18

Initial below to acknowledge the graduation requirements that you must fulfill in order to be eligible for graduation:

• Attend seven of the 10 class sessions AND the Project Presentation Practice Night
• Volunteer at a Town-hosted event or program
• Participate in a class service project
• Attend one Town Council meeting 
• Attend one Town Commission meeting

 *

Initial below to acknowledge the graduation requirements that you must fulfill in order to be eligible for graduation: Attend seven of the 10 class sessions AND the Project Presentation Practice Night Volunteer at a Town-hosted event or program Participate in a class service project Attend one Town Council meeting Attend one Town Commission meeting

Participants will be notified the week of Nov. 18 via email. Please make sure to check your spam folder for notification. Thank you!

1. To receive a copy of your submission, please fill out your email address below and submit.
2. Email Address

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