Personal Info:

Last Name First Name Middle Initial

Birth Date Female Male Years in Shawano County Area

Home Address:

Street City Zip Phone

Employment:

Present Employer (if any) How long

Street City Zip Phone

Present Title or Responsibility Since

Phone Phone Email

Where do you prefer to receive mail for this class? Home Work

Do you anticipate an out-of-area transfer within the next year? Yes No

How many days per month does your work require you to be out of town?

Present Community Involvement:

How much time each month do you commit to community, civic, professional or other organizations and activities?

1-2 hours 3-4 hours 5-6 hours 7-8 hours 9-10 hours over 10

Please list organizations or activities you have been involved with here or in other communities.  If you are not currently involved in community activities, list your areas of community interest.

What accomplishments are you most proud of from your participation in any one of the previously named organizations and activities?

Please check the areas of volunteer and community service you wish to become more involved:

It is an expectation that upon completion of this program you will use the skills learned, knowledge gained and connections made to improve the quality of life in Shawano County. Special terms can be arranged to pay by January 2012 if this fits better into a fiscal budget.

Tuition

If accepted into the LEADERSHIP Shawano County program, you or your employer/sponsor will be billed for the tuition of $600, which covers all program costs, including meals and materials.

Tuition fees will be paid by:
Applicant’s Portion..................................................$

Employer/Sponsor Portion.......................................$

Total…………………………………………........$ 600.00

Scholarships for a portion of the tuition may be available as funds permit.

Will you need assistance in the form of a scholarship? Yes No

Commitment

To graduate from LEADERSHIP Shawano County, a participant is expected to attend all sessions in their entirety including the ORIENTATION, all full-day sessions,  and graduation. 

Applicant’s Personal Statement:

On a separate sheet of paper, please answer the following questions.  Your responses should be typed and double spaced, or printed.

1.  Name someone significant to you who has inspired you as a leader.  What about this person do you most admire?
2.  Why do you want to be a participant in this program?  Do you have any personal leadership goals?
3.  What do you believe are two or three significant issues/challenges facing Shawano County communities?

I understand the purposes and expectations for the Leadership Shawano County program and if I am selected, I will devote the time and resources necessary to complete the program.  Even though emergencies do arise, I understand any participant missing the orientation, graduation or more than two sessions, may be asked to withdraw from the program and no portion of the tuition shall be refunded. I understand the above commitment and agree to be bound by them in signing this application.

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Applicant Signature                                                                                             Date

Employer Commitment (if applicable)

This applicant has our full support which includes the time required to participate in the program.

______________________________________________________________________________
Firm Name
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Signature                                                                               Title