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Name ____________________________________________________________Title_______________________________
Employer __________________________________________________________Email____________________________
Business Address ____________________________________________________Business Phone____________________
Cell Phone___________________
Community Involvement
Please list any organizations/service clubs/churches/business groups which you are a member or have been active in previously .
What do you hope to gain from the Leadership Portage County experience?
Attendance Commitment Leadership Portage County requires participation all day (approximately 8:00 to 4:30 p.m.) starting with a mandatory two day retreat on Sept. 17 and Sept. 18, 2015 . The program dates will then be held on Thursdays:
1.
Thursday, September 17, 2015
October 08, 2015
2.
Friday , September 18, 2015
3.
5.
7.
9.
December 03, 2015
February 4, 2016
April 07, 2016
4.
6.
November 5, 2015
January 14, 2016
8.
March 3, 2016
10.
May 05, 2016
If admitted to the LPC program, you (or your company or sponsoring organization) agree to pay $1,750 in tuition, which is nonrefundable. Deadline for applications July 15, 2015. All applicants will be notified of their acceptance status by July 31, 2015.
Tuition is due no later than Aug. 1, 2015 . The tuition fee covers all program costs. We also offer installment payments. Any class member who misses two class sessions will be asked to leave the program and will not receive a tuition refund. The following section must be completed for your application to be accepted:
Employer $________ Personally $________ Request partial scholarship $_________(Not to exceed $500)
Are you and your employer able to commit to the program requirements above? Yes ___ No___
1.
LPC Applicant Signature:_____________________________________________________________ Date________
This candidate has my full support to participate in Leadership Portage County:
2.
Supervisors Signature: _______________________________________________________________ Date________
___ We would like to make tuition installment payments of _____ per month or ____ two budget year payments
Partial Scholarships
On a limited basis, Leadership Portage County offers partial scholarship assistance to those who are not sponsored by an employer and demonstrate strong financial need. Scholarships are awarded on a basis of proven financial need and the amount of funds available each year. LPC reserves the right to request a follow-up interview with each scholarship applicant. If you would like to apply for a scholarship, please attach a separate sheet outlining your financial need.
Applicants for participation, admission, employment, sources of referral for participation, admission and employment and all organizations, entities, private and public which have association with Leadership Portage County are hereby notified that LPC does not discriminate on the basis of race, religion, national origin, creed, or ancestry, age, gender or disability in admission or access to its programs or activities. It is the goal of LPC to welcome as many qualified candidates as possible. However, due to class size restrictions, some candidates may be asked to reapply in the future. Persons with disabilities needing special arrangements to participate are asked to contact the Executive Director of LPC by July 1, 2015.