Connection Academy Application

Date

First Name

Last Name

Email *

Phone *

Business Name *

Website *

Professional Background

Education, degrees, licenses, certifications, or professional credentials, if applicable: *

Years of experience in your profession or industry: *

Have you ever had a professional license revoked or suspended? *

Yes

If yes, please explain:

Commitments

1. For virtual sessions, I agree to be camera-ready with my camera on and participate fully in the experience.

2. I understand that Connection Academy is a six-session program and I am committing to attend all six sessions. I will arrive

on time and remain for the entire scheduled session.

My Signature

Clear

By checking this box, I consent to receive non-marketing text messages from Network Arkansas about Events and classes. Message frequency varies, message & data rates may apply. I also consent to receive marketing and promotional messages including special offers, discounts, new product updates among others, from Network Arkansas at the phone number provided. Frequency may vary. Message & data rates may apply. Text HELP for assistance, reply STOP to opt out.