Leadership A2Y
Application 2015-2016
September 25, 2015 - Deadline for application and $50
application fee
Personal Information:
Full name:
How you would like your name on your name tag:
Title:
Employer:
Business Mailing Address:
Business Mailing City/State/Zip:
Business Phone:
Work email:
Personal email:
Cell/Alternate Phone:
Food Allergies/Dietary Restrictions:
Physical Restrictions:
Fleece Size (men’s): S, M, L, XL, XXL
Personal Statement:
Since each Leadership A2Y class is intended to be diverse, it is important for the
members of the Leadership A2Y review committee to learn more about you. The
committee members will also evaluate your commitment to the program. Please
use an additional sheet of paper to answer the following questions:
1. What are the reasons you want to participate in the Leadership A2Y program?
2. What do you think are the significant issues facing the Ann Arbor / Ypsilanti
region?
3. What responsibility do individuals have to help solve community problems?
Tuition and Application Fee:
The tuition for the Leadership A2Y program is $1,500 for Chamber Members and
$2,000 for Prospective Chamber Members. The tuition covers program costs for an
Impact ticket, Orientation, the Retreat, and the eight monthly sessions, including
meals and most transportation costs from the program’s point of origin. In
addition to tuition, there is a $50.00 non-refundable application fee.
Leadership A2Y
Application 2015-2016
**A limited number of partial scholarships are available through the Leadership
A2Y Scholarship Program. Requests for financial assistance do not affect
consideration for participation. Scholarship applicants must be A2Y Regional
Chamber members and preference will be granted first to employees of non-profit
organizations. To be considered for financial assistance, you must complete a
Scholarship Application and submit it with the Leadership A2Y Program
Application.
Are you requesting financial assistance? ____Yes ____No
Commitment:
Leadership A2Y requires commitment, prioritization and dedication. Each
participant is required to attend every session from the orientation to the overnight retreat and the monthly class sessions. If a class member is absent in excess
of two (2) sessions, they forfeit their eligibility to graduate.
Cancellation Policy:
An applicant’s place is secured in the class as soon as he/she is notified in writing
of his/her acceptance, and when tuition is paid in full. Applicants are encouraged
to send payment with their applications. Full tuition payment is due by October 7,
2015, the day of Orientation. If the applicant submits their application after
October 1st, tuition payment must be sent with application.
If payment is not received, or if arrangements to make necessary payment(s) are
not made with the Chamber, the applicant’s place in the class will not be secured
and may be given to another. All requirements stated herein apply to scholarship
recipients as well as non-scholarship recipients. If an applicant must cancel or
forfeits his/her place within the class, a $100 cancellation fee will be charged at
the discretion of the A2Y Regional Chamber. If an applicant cancels within 10 days
prior to the Retreat, one-half of the full tuition will be forfeited. If an applicant
cancels after the Retreat, the entire tuition will be forfeited and no refunds will be
granted. Thank you for your understanding.
I understand the attendance, payment, and cancellation requirements of the
Leadership A2Y program. If selected, I will pay the tuition.
Signature: __________________________________ Date: _____________
Leadership A2Y
Application 2015-2016
We would be pleased to provide you with additional information should you have
any questions or concerns. Please contact the A2Y Regional Chamber by phone:
734.665.4433 or fax: 734.665.4191 or email inquiries to
Rosalind@a2ychamber.org or Barbara@a2ychamber.org.
Send completed application along with Tuition and the $50 non-refundable
Application Fee to:
Leadership A2Y
A2Y Regional Chamber
115 West Huron Street, 3rd Floor
Ann Arbor, MI 48104-2303
Or Fax: 734.665.4191
Chamber Member
Application Fee
Tuition
Total
$50
$1,500
$1,550
Prospective Member
Application Fee
$50
Tuition
$2,000
Total
$2,050
Method of Payment
� Check, payable to the A2Y Regional Chamber
� Visa ______________________________________________
Credit Card Number/Expiration Date/3 Digit Security Code
� MasterCard ________________________________________
Credit Card Number/Expiration Date/3 Digit Security Code
� American Express ___________________________________
Credit Card Number Expiration Date/5 Digit Security Code
� Discover___________________________________________
Credit Card Number/Expiration Date/3 Digit Security Code
Signature:_________________________________Date:__________