Leadership A2Y 2.0
Application 2015-2016
September 18, 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 2.0
program?
2. Have you attended any previous leadership training seminars, courses or
programs? Please list all.
3. Are you currently in a leadership position in your place of employment and/or
community? Please list all.
4. What issues do you and/or your organization face in terms of leadership?
Tuition and Application Fee:
The tuition for the Leadership A2Y program is $2,500 for Chamber Members and
$3,000 for Prospective Chamber Members. The tuition covers program costs for
books, assessments and the six monthly sessions, including meals. In addition to
tuition, there is a $50.00 non-refundable application fee.
Leadership A2Y 2.0
Application 2015-2016
Commitment:
Leadership A2Y requires commitment, prioritization and dedication. Each
participant is required to attend every session. If a class member is absent in
excess of one (1) session, they forfeit their eligibility to graduate. The day and half
retreat on September 29th and 30th will be mandatory attendance.
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
September 28, 2015.
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. 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 2.0 program. If selected, I will pay the tuition.
Signature: __________________________________ Date: _____________
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.
Leadership A2Y 2.0
Application 2015-2016
Send completed application along with Tuition and the $50 non-refundable
Application Fee to:
Leadership A2Y 2.0
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
$2,500
$2,550
Prospective Member
Application Fee
$50
Tuition
$3,000
Total
$3,050
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:__________