2013 APPLICATION FORM Leadership Northwest is a dynamic leadership development training course for current and emerging community leaders. The course includes nine months of intensive training (one day-long session each month), which focuses on leadership development and knowledge of the community. To be considered for the program, please complete this application. 1. Download the Application Form. Once the form is completed, save the form to your computer, and email it to bpayne@nwtcc.org with a digital photograph of yourself. 2. Remit application fee (if applicable) by check. (No application fee if received by July 19, 2013. $50 application fee if received on or after August 16) 3. Print the Class Calendar and retain for your records. You may want to pencil the Class dates in your calendar. Your application, application fee, photo and recommendation form must be received by Leadership Northwest no later than Friday, August 16, 2013. Incomplete or late applications may not be considered. Do not remit tuition payment with your application. The 2013-2014 Leadership Northwest class will be announced the week of August 26, 2013. The Selection Committee (Leadership NW Board) is looking for applicants who: Have been involved in volunteerism and want to strengthen leadership practices to enhance their potential. Serve in a leadership capacity in organizations related to their profession, academic institution or other young professional organizations. Typically, they are considered rising stars in business, government, non-profit, the service sector or as an entrepreneur. Aspire to become actively engaged in Northwest Tarrant County through decision making roles on community boards and city commissions. Possess high standards of personal quality and integrity. Can and will commit the time required for the program. If employed, have the endorsement of their employer or indication the employer does not object to their taking time off from work for Leadership Northwest activities. PARTICIPATION IS A TWO-YEAR COMMITMENT! Leadership Northwest is designed to be a learning experience. Therefore, it requires the following commitments on the part of those who participate: 1. Attendance at the Retreat in September. 2. Attendance at the eight monthly classes and a limited number of outside hours. See attached schedule. Note: Dates and times are tentative and may be altered. Significant notice will be given to attendees regarding changes. 3. Anyone absent from more than twelve (12) hours of Class Days will not receive a certificate of completion. 4. No refunds will be made after the first class in September. 5. Employers must agree to give participants leave time for scheduled sessions. 6. Applicants agree to refrain from running for public office during the course of Leadership Northwest unless they withdraw from the class. 2013 APPLICATION FORM LEADERSHIP NORTHWEST CLASS OF 2013-2014 For Office Use Only Application received on: _____________ EARLY BIRD DEADLINE FOR APPLICATION: Friday, July 19, 2013 – No Application Fee FINAL DEADLINE FOR APPLICATION: Friday, August 16, 2013 – Fee $50 Application Fee: ___________________ Photograph: _______________________ CONSIDERATION FOR SCHOLARSHIP REQUESTED See the last page of the application form for information. YES NO (double click to CHECK) Recommendation: __________________ PLEASE TYPE: Name: Last First Middle Company: Current Position Business Address: Business Phone No. of Employees Mailing Address City FAX Email Address State Profit Type of Business Home Address: Mailing Address Home Phone Date of Birth Nickname City Cell Phone Month Ethnic Background: (double click to check) / Day / Year Anglo Asian Zip Non-Profit State Zip Spouse Male Female (double click to check) African-American Hispanic/Latino Native American Multi-racial 2013 APPLICATION FORM Describe Your Position and Responsibilities At Your Current Employer: Tell Us About Your Community Involvement: List any community, civic, professional, educational and religious organizations in which you have been involved. (If you have recently moved to the area, please list activities in which you were involved in your previous community.) Organization: Dates/# hrs per month: Nature of Participation: What is one issue facing Northwest Tarrant that you, personally, are concerned about? How would you use your leadership training to benefit the community? Why do you want to participate in Leadership Northwest? What specific skills/knowledge do you hope to gain? I do have the full support of my employer for the time required to participate in Leadership Northwest. Tuition for the program is $450, payable by September 5, 2013. Send statement for $450 tuition to: (Check one and provide name and mailing address.) Company Organization Send Invoice to (address): Applicant Other Information on Scholarships Limited scholarships are available. All applicants are responsible for at least $225. Partial scholarships are awarded solely on the basis of documented financial need and availability of tuition scholarship dollars. Proof of financial need may be requested. Scholarship amount requested: $ 2013 APPLICATION FORM If you are requesting a scholarship, please explain the circumstances. It is my understanding that Leadership Northwest is a learning experience and requires attendance at each session. The Opening Retreat, which is mandatory, will be September 12, 2013. Subsequent Class Days will be held from 8:30am – 5:00 pm on the 2nd Thursday of each month from October - May. Any participant missing any part of The Opening Retreat or more than twelve (12) hours of the Class Days will not graduate. Leadership Northwest Calendar DATES September 10, 2013 DAY Tuesday EVENT Alumni/New Class Get Acquainted Reception Opening Retreat TIME 6:00 p.m. – 7:30 p.m. HOURS 1.5 *September 12, Thursday 8:00 a m - 5:00 p m 9 2013 October 10, 2013 Thursday Class Day 8:30 a.m. – 5:00 p.m. 8.5 November 14, 2013 Thursday Class Day 8:30 a.m. – 5:00 p.m. 8.5 December 12, 2013 Thursday Class Day 8:30 a.m. – 5:00 p.m. 8.5 January 9, 2014 Thursday Class Day 8:30 a.m. – 5:00 p.m. 8.5 February 13, 2014 Thursday Class Day 8:30 a.m. – 5:00 p.m. 8.5 March 13, 2014 Thursday Class Day 8:30 a.m. – 5:00 p.m. 8.5 April 10, 2014 Thursday Class Day 8:30 p.m. – 5:00 p.m. 8.5 May 8, 2014 Thursday Class Day 8:30 a.m. – 5:00 p.m. 8.5 *June 12, 2014 Thursday Graduation TBA (*) Denotes a mandatory meeting--all participants must attend its entirety in order to graduate. I hereby give Leadership Northwest the right to make inquiries regarding the information provided on this application and have my employers consent to fully participate in this program. Signature Date Employers Signature Date The size and composition of each Leadership Northwest class is carefully considered to ensure that it is broad based, representing a variety of professional, economic, social, and ethnic backgrounds. Consequently, many highly qualified applicants may not be accepted the first time they apply. We encourage you to re-apply should you not be accepted this year. Your application, application fee (if application is received on or after August 16, 2013), and photo must be received by Leadership Northwest no later than Friday, August 16, 2013. All Leadership Northwest application materials should be submitted by email to bpayne@nwtcc.org or via U.S. mail to: Leadership Northwest, 3918 Telephone Road, Ste. 300, Lake Worth, TX 76135