LDI PARTICIPANT PROFILE INFORMATION FORM 2010
 
 
First Name
Last Name
Job Title
Organization/Employer
Organization Street Address:
Office City and State
Office Zip Code
Office Phone
Office Phone Extension
Office Fax
Email
Home Street Address:
Home City and State
Home Zip Code
Home Phone
Cell Phone
Area/Neighborhood/Municipality
Biographical Sketch (250 words or less, please):
Name of Spouse/Significant Other (if applicable)
Names and Ages of Children:
Education (degrees received, institutions, and date of receipt):
Board service:—boards of directors or advisory committees on which you serve, including any leadership roles:
Volunteer activities—organizations of which you are a member, or where you volunteer:

Interest Index
Please check your areas of interest.
If other, please describe:

Areas of Expertise/Professional Skills:
Please indicate skill sets that you possess and want to leverage as a leader to create civic change through volunteering, serving on boards, committees, taskforces, etc.
If other, please describe:

Would you be interested in being placed on a board or engaging in board matching conversations through Leadership Pittsburgh Inc.?
Place of birth:
Childhood Ambition:
Fondest memory:
Retreat:
Wildest Dream:
Proudest Moment:
Biggest Challenge:
Perfect Day:
First Job:
Indulgence:
Inspiration:
Favorite Movie:
Favorite Book:
Favorite Musical Groups:
Favorite Quote:
Dream Vacation:
Three things that can always be found in your refrigerator:
The person you would most like to have dinner with:
Pittsburgh’s best kept secret:
One thing that you would like to do to change/have an impact on Pittsburgh:
Three words that best describe you:
Something we should not know about you:
Phonetic Pronunciation First Name
Phonetic Pronunciation Last Name
Salutation/Nickname (this name will appear on your name tag)
Please describe any physical conditions you have, if any, that require special equipment or assistance:

Do you have any special dietary needs (vegetarian, kosher, vegan, diabetic, etc.) or food allergies that we should be aware of?
If yes, please specify: