Word process
Applications can be downloaded from web site
39 Public Square, Ste. 202 – Medina, OH 44256
Phone: 330-721-7118 FAX: 330-721-7299
www.leadershipmedinacounty.org
Name (Prefix, first, last):
Preferred First Name:
Home Address:
Home/cell Phone:
Present Employer:
Business Address:
Business Phone:
Email address:
Fax Number:
Present Title or Responsibility:
Years at present job:
Place of Residence (Name of Township, Village, City):
Years living in Medina County:
(Please Check) Preferred Mailing Address:
Business
Highest Level of Education, and/or specialized training:
School and location:
Dates:
Home
Major:
Significant Achievements, Honors/Awards:
Hobbies and special Interests:
Previous employment (list two most recent, include active military duty if applicable):
Employer
Title/Responsibility
From-To
Reason for Leaving
Business/Professional Affiliations (please no acronyms) in which you take (have taken) an active role:
Business/Professional Organization Name
Dates of Membership
(Leadership) Positions Held
What do you consider your most significant responsibility, career achievement or skill to date?
Please indicate the category that describes your present position:
Business/Industry
Financial Services
Media/Advertising
Social Services
Religious
Banking
Labor
Medical/Hospital
Education
Law
Government
Not for Profit
Other:______________________________________
Community Activities (community, civic, religious, political, government, social, athletic or other) in which you
take (or have taken) an active role in order of importance. (Please, no acronyms)
Organization
Dates of Membership
(Leadership) Positions Held
Hours Volunteered/Month
What has been the most significant volunteer accomplishment? What was the nature and scope of your
contribution?
Why do you want to be part of Leadership Medina County? Why now?
What would you consider your leadership strengths? Explain
What unique experience(s) would you as a class member bring to Leadership Medina County?
What life event or experience has most shaped you as a leader?
What are your long term civic/volunteer objects after your leadership year? (Project 3 years)
Essay
Leadership Medina County educates, connects and involves leaders in the community who enhance their problem solving
and abilities by sharing perspectives and working together. With this in mind briefly describe an experience in which you
sought or were assigned a leadership role. What did you learn from the experience about leadership and about yourself.
(Please limit your response to one side of one sheet of paper)
References: List two people, including Leadership Medina County graduates, who are knowledgeable about your
leadership performance and potential.
Name:
Phone:
Name:
Phone:
Have you applied to Leadership Medina County before? ___ Yes ___ No
How did you hear about LMC? ___ LMC Alumni ___ Awareness Breakfast ___ Social Media ___News article
___ Other: _________________________
Applicants and Employers Understanding:
We understand the purpose of the Leadership Medina County program and that completion of this application does
not ensure a candidate’s acceptance in the class. If selected to participate, the applicant will be permitted to devote
the time (approximately 10 days) required for the program and tuition will be paid as required. We have reviewed the
program dates and understand the opening retreat is mandatory. We understand that this program may require time
outside of the class days.
____________________________
________________________________
Employer’s Signature
______________________
Applicant’s Signature
Print: ________________________
Date
________________________________
Tuition for participation in Leadership Medina County is $1,700.00. Each participant is expected to pay a minimum of
10% of the tuition; the remaining balance may be paid by the employer, sponsoring organization or the individual
participant. Do not submit payment with this application. Limited tuition assistance based on need is available. Please
request a Tuition Assistance Form from the office.
You will be contacted for an interview by a Leadership Medina County Trustee or Selection Committee Member.
Mail/Email completed application and essay by April 30 to:
Executive Director, Leadership Medina County
39 Public Square, Suite 202
Medina, OH 44256
Email: exec@leadershipmedinacounty.org
(330) 721-7118 Fax: 330-721-7299
All applicants will receive written notification of their acceptance status in mid June.