2015
Application for Word Process
Name:
Home Address:
Home/cell Phone:
Years living in Medina County:
Present Employer:
Business Address:
Business Phone:
Email address:
Fax Number:
Best day and time to contact you for an interview:
Present Employer:
Business Address, phone, fax:
Present Title or Responsibility:
Years at present job:
(Please Select) Preferred Mailing Address: Business or Home:
Highest Level of Education, and/or specialized training:
School and location, Dates, Major
Significant Achievements, Honors/Awards:
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?:
Previous Employment (list two most recent, include active military duty if applicable).
Employer, Title, Dates, 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 or 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, or Other
Why do you want to be part of Leadership Medina County? Why now?
2015
Application for Word Process
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 objectives after your leadership year? (Project 3 years)
Essay
Leadership Medina County educates, connects and involves leaders in the community who enhance their
problem solving 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. (2 page limit)
References: List two people (name and phone number), including Leadership Medina County graduates, who
are knowledgeable about your leadership performance and potential.
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: _________________________
Tuition for participation in Leadership Medina County is $1,750.00. 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.
Please email your application to exec@leadershipmedinacounty.org.
Your application is not complete unless we also receive the Applicant and Employer Understanding form
by April 30, 2014.