2014-2015 CONFIDENTIAL APPLICATION
All applications will be handled in strict confidence. Please limit responses to the spaces provided.
Name:
Preferred name:
Home address:
__________ Years in Ashtabula County:
Home Phone:
_______ Cell Phone Number:__________________________________________
Preferred mailing address:
Home or Business
E-Mail:
____________________
Emergency Contact Information (Name & Phone):___________________________________________________________
Part 1: PARTICIPATION
A.
B.
C.
D.
Orientation Retreat (Full attendance is required.)
Ten Full Program Days (80% attendance is required for graduation.) Applicant understands the obligation to attend
each Program Day in its entirety.
Class members are expected to participate fully in program planning activities and committees.
Do you have the full support of your employer and family for the time required to effectively participate
in the LEADERship Ashtabula County program?
Part 2: EMPLOYMENT
Current Employer:
Hire Date:
Business address:
Phone:
________________________________________
_____________________
Fax:
_______________
_______
Type of organization:
Your title:
Part 3: EDUCATION
Name and city of school
Post-Secondary:
Graduation Date
Degree/Major
_
Post-Graduate: ____________________________________
______
_______________
__________________________
Part 4: ORGANIZATIONS / ACTIVITIES / COMMUNITY INVOLVEMENT
Organization(s) where you currently volunteer and a description of the responsibilities:
List, in order of importance to you, organizations of which you have been a member (i.e. community, professional, organized
labor, religious, social, athletic, etc.):
Organization
Dates of Membership
Official Position Held
What have you accomplished in any of these activities you believe to be a significant leadership role?
Part 5: GENERAL
What do you hope to gain and how do you expect to utilize your LEADERship Ashtabula County experience?
In your judgment, what are the two most pressing issues facing Ashtabula County today?
Explain why and give any recommendations you may have for approaching and resolving these issues.
Part 6: TUITION
Tuition for the 2015 class is $2000. How will your tuition be paid?
Employer
Personally
Other (please specify)
If you need financial assistance, please call the LEADERship office for more information.
I understand the purpose of the LEADERship Ashtabula County Program and that completion of this
application does not ensure acceptance into the class. If selected to participate, I will devote the time
required and make tuition payments in a timely manner.
Applicant’s signature:
Please mail application to:
Date:
LEADERship Ashtabula County, Inc.
PO Box 643 3441 North Ridge West
Ashtabula, OH 44005-0643
440-998-3888/ Fax: 440-992-2474
E-mail: leadership@suite224.net
www.leadershipashtabulacounty.org
LEADERship Ashtabula County, Inc.
References
Name of Applicant:
Please list three references, at least one being a LEADERship Member.
Name:
Affiliation:
Address:
City:
Phone: (
State:
Zip:
State:
Zip:
State:
Zip:
)
Name:
Affiliation:
Address:
City:
Phone: (
)
Name:
Affiliation:
Address:
City:
Phone: (
)
We are a network of individuals – working individually and collectively – strengthening community.
LEADERship Ashtabula County
FACT SHEET
THE PROGRAM
LEADERship Ashtabula County begins in September with orientation, an overnight
retreat, and continues through June with ten one-day sessions, ending with
graduation in June. The sessions are conducted by leaders in their fields who will
cover topics related to the specific day. Each committee will be lead by a
facilitator/day chair LEADERship graduate.
2014-2015 LEADERship CLASS DATES
Orientation
Opening Retreat
Heritage Day
Agriculture Day
Business, Labor, Economy Day
Health & Human Services Day
Mid Year Retreat
Government & Political Systems Day
Public Safety & Justice Day
Education Day
Quality of Life Day
Closing Day & Evening Graduation
Thursday, September 18, 2014 (1 hr, 4:00 PM)
Sunday-Tuesday, September 21-23, 2014
Wednesday, October 15, 2014
Wednesday, November 19, 2014
Wednesday, December 17, 2014
Wednesday, January 14, 2015
Friday, January 30, 2015
Friday, February 20, 2015
Wednesday, March 18, 2015
Wednesday, April 22, 2015
Wednesday, May 20, 2015
Friday, June 12, 2015
ATTENDANCE REQUIREMENTS
1. Attendance at the retreat is mandatory. The retreat begins at 5:00 PM on Sunday, September 21st through
Tuesday morning, September 23rd. The Retreat will be held at Peek n Peak Resort.
2. Participants are expected to attend all full one-day programs in addition to the opening retreat. Program
days may begin around 7:00 AM and last until 6:00 PM. Eighty percent attendance is required for
graduation. The year end wrap-up is also mandatory.
3. Attendance for less than a full program day may be counted as an absence.
4. The LEADERship Ashtabula County office must be notified prior to or immediately following an absence.
5. Each class member is assigned to a planning committee for a program day and is expected to fully
participate in program planning activities.
TUITION
Tuition for the 2014-2015 LEADERship Ashtabula County class is $2000.00. Payment is due prior to the
opening retreat unless arrangements have been made in writing with the Executive Director.
Please return the completed application to:
LEADERship Ashtabula County
PO Box 643, 3441 North Ridge West Ashtabula, OH 44005-0643