Registration Form

Interconnected Leader

11 week virtual program from 20 March to 29 May 2025

First Name

Last Name

Email

Mobile Number

PO Box or Street Address

City

Post Code

State

Country

Your Age Range

Gender

Are you of Aboriginal / Torres Strait Island or First Peoples Origin?

YesNo

Do you have a referral code?

Please enter your referral code

Your organisation name (employer or own business)

Position or title

How would you describe your current organisation?

SolopreneurFor ProfitNot for Profit/ CharityBCorp or Social Enterprise (registered with Social Traders)First Nations OwnedGovernment

How many people work in your Organisation?

Micro (1-4 ppl)Small (5-19)Medium (20-80 employees)Large 80+

Which industry or sector do you primary work in?

Advertising & Design	Agriculture, Forestry & Fishing
Architecture, Housing & Construction	Arts & Entertainment
Community & Social services	Computer & Technology
Education & Training	Energy & Climate
Engineering	Fashion & Retail
Financial Industries	Hospitality, Food & Beverage
Government, Public Administration & Policy	Healthcare & Pharmaceutical
Legal	Manufacturing & Trades
Media, Marketing & Communications	Mental Health & Wellbeing
Mining	Professional Services
Science & Research	Tourism & Recreation
Transportation	Wildlife & Nature Conservation
Other

If other, please specify

Please share your Linked In Profile (if you have one)

Please share your company or personal website (if you have one)

How did you hear about this course?

Referrer Name

Other Referrer

Owner ID

This is the Owner ID of David

Campaign ID

This is the Campaign ID for this form - Interconnected Leader - March - May 2025 (Form ID: 5152291)

Program ID

This is the Program ID for this form - Interconnected Leader - March - May 2025 (Form ID: 5152291)

How would you prefer to pay for this program? (All referral invoices paid by invoice)

By Credit CardBy Invoice

Total Amount to be paid to Small Giants Academy Limited including GST

Price is shown in AUD

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Name on Card

Card Number

Code

Billing Email

I understand that by submitting this form I am agreeing to pay for this program by the invoice due date, in accordance with Small Giants Academy Terms and Conditions.

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