ExecLX Participant Form

Welcome to The Executive Leadership Experience (The ExecLX)

We’re so glad you’re ready to take the next step toward advancing your individual, team, and business impact. During this nine-month experience, you will engage in facilitator-led learning (both onsite and virtual), peer-based connections, and 1:1 executive coaching.

But first, it’s important that we ensure you will be surrounded by peers who are dealing with similar experiences and challenges. Please answer the following questions so we can get to know you better. This information will be used for the sole purpose of enrolling you in The ExecLX and bringing you a personalized leadership development experience.

All fields are required, with the exception of questions not marked with an *.

First Name

Last Name

Job Title

Organization Name

City

Country

Assistant Name (if we need to work with your assistant to coordinate logistics)

Assistant Email

LinkedIn Profile

Phone (your best contact number)

State/Province

Total # of Employees in Your Organization

Budget That You Manage

# of Employees Reporting to You Directly

# of Employees Reporting to You Indirectly

How many years have you been in an executive leadership role?

What are your primary responsibilities in your role?

What are your top 2-3 leadership challenges in your role?

What, if any, job transitions are you preparing for?

What do you hope to gain by completing The ExecLX?

We are looking for participants who have the desire, commitment, and capacity to learn and apply a growth mindset, because that will elevate the ROI for you and your organization. During this 9-month experience, you’ll have the opportunity to participate in: • Two (2) 2-day onsite sessions • An average of three (3) hours per month of virtual sessions • Three (3) virtual peer problem-solving sessions • Three (3) virtual meetings with an executive coach. *** Are you willing to make the commitment to learn and invest the time necessary to complete The ExecLX — over the next 9 months?

Yes

Please indicate any dietary restrictions below:

Within The ExecLX program, it is understood by all that the coaching relationship that occurs will be a benefit to the IT community as a whole. By checking the box below, you agree that you shall not, directly or indirectly, solicit for employment or any independent contractor relationship from anyone in the program.

I agree

Questions? Need additional assistance?

Contact Bethany Dustin:

603-623-7373 or bdustin@ouellette-online.com

Ouellette & Associates

Welcome to The Executive Leadership Experience (The ExecLX)

Questions? Need additional assistance?

Contact Bethany Dustin:

603-623-7373 or bdustin@ouellette-online.com

Ouellette & Associates Consulting, Inc.