Membership Application

1Administrative Information

2Team Dynamics

3Self-Awareness

4Improvement Areas

Name *

First

Last

Email *

Confirm Email

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Date of Birth *//

Do you have children? *

Occupation *

Job/Business Title *

Provide a brief description of your job or business duties *

Team Awareness

PUSH is about the community and us each doing our part individually (working to be better and more productive) to make the cohesive unit stronger overall. We all attain more together than we can being apart.

Are you willing to make the necessary adjustments to your personal life to meet with your designated PUSH team once a week (currently Sunday or Monday evenings) via Zoom? *

Are you willing to assist, support, encourage, and share information at will (in any way you can), with other PUSH community members in an effort to increase the overall community dynamics? *

What does it mean to you to be a team player? *

What motivates you? *

Items Knowledgeable About

Is there anything that you do or have an interest in that you would consider yourself relatively knowledgeable about and could potentially help other with? Please document item(s) below. Note: If none enter "N/A".

1st Item (Knowledgeable About) *

2nd Item (Knowledgeable About) *

3rd Item (Knowledgeable About) *

My Hobbies

Please list your 3 favorite hobbies or pastimes?

Hobby 1 *

Hobby 2 *

Hobby 3 *

Items Your Consistent With

Identify three (3) things which you find yourself to be most consistent with doing and your reason for each. Note: Some examples are spending time with family/friends, exercising, reading, leisure time, working on your business, financial planning, career related items after hours (certifications, degrees), etc.

Current Consistent Item 1 *

Current Consistent Item 2 *

Current Consistent Item 3 *

Items Your Procrastinating On

Please identify three (3) tasks which have been on your "to-do" list for 3 months or longer which you've procrastinated on doing. Note: Some examples are organize/rearrange your closet, exercising regularly, home improvement work, spending intentional time with your kid(s), career/business advancement items, etc.

Procrastination Item 1 *

Procrastination Item 2 *

Procrastination Item 3 *

Things You Want to be Doing

Please Identify three (3) things which you currently are not doing, that you would like to be doing and the reason why you've been failing to do each. Note: Note: Some examples are spending time with family/friends, exercising, reading, leisure time, working on your business, financial planning, career related items after hours (certifications, degrees), etc.

Desired Consistent Item 1 *

Desired Consistent Item 2 *

Desired Consistent Item 3 *

Personal and Professional Improvement

What aspects of your personal and/or professional life are you most interested in improving currently? Please identify in order of importance to you, your top 5 focus areas.

1st Priority Focus *

2nd Priority Focus *

3rd Priority Focus *

4th Priority Focus *

5th Priority Focus *

What do you want?

What do you consider to be your primary focus professionally? *

Sustaining your career
Advancing your career
Starting your business
Growing your business
Sustaining your business

What is the most significant goal, that if worked on consistently, would give you the greatest sense of accomplishment when you look back on your life 3 years from now? *

What do you hope to receive most from PUSH to assist with accomplishing your most significant goal? *

Accountability
Community Support
Competition
Guidance/Instruction
Increased Focus
Networking
Perspective
Planning/Structure
Sense of Urgency