Leadership application 2015-16

advertisement

This form must be typed or printed in black ink. Please fill out as completely as possible but limit answers to the space provided.

A $50 deposit is required with the application. The deposit will be applied to tuition

or refunded if not selected. Applications due: August 14, 2015.

1. Personal Information

_____________________________________________________________________________________

Last Name First Middle Preferred Name

_____________________________________________________________________________________

Home Address City ST ZIP

_____________________________________________________________________________________

Employer (if applicable) Position

_____________________________________________________________________________________

Employer’s Address

City ST ZIP

__________________________

Phone Number

_________________________

Fax Number

_________________________ e-mail address

Briefly describe job responsibilities if you are employed, or your chief activities if you are not employed.

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

How long have you lived or worked in Haywood County?_______________________________________

Spouse’s name (if applicable)______________________________________________________________

Children (names and ages)

______________________________________________________________________________________

______________________________________________________________________________________

_____________________________________________________________________________________

2. Organizations and Activities

Please list, in order of importance, up to five community, political, professional, civic, business, religious, social, athletic or other organizations in which you have been involved.

Activity/Organization Date Responsibilities

What have you accomplished in these activities that you think is important?

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

Other interests/or hobbies_________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

Interesting facts about you_______________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

3. Education

Please outline your academic background, training and continuing education experiences.

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

_____________________________________________________________________________________

List your extracurricular activities and special honors awarded for leadership activities.

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

4. Participation

In order to accomplish our objectives, the full participation of each individual selected is necessary. Will you be able to fulfill such a commitment? ____________________________________________________

Do you have the support of your employer for the time required to participate in the Leadership Haywood

County experience? _____________________________________________________________________

Attendance is mandatory for Leadership Orientation. You are allowed to miss *two* class sessions – your third absence will disqualify you from graduation – no exceptions. Partial day attendance counts as an absence.

All class sessions last a full day. Leadership Orientation is an overnight stay at Our Lady Queen of Peace

Retreat Center in Dancyville, Tennessee. Your tuition includes the cost of all meals, transportation, and class supplies.

An Agenda of Sessions (with Tentative Dates):

Leadership Orientation - September 17&18, 2015-Our Lady Queen of Peace, Dancyville, TN

Economic Development and Agriculture - October 8, 2015

Quality of Life - October 29, 2015

Public Safety and Justice - November 19, 2015

Local Government and Infrastructure - December 10, 2015

Healthcare and Social Services - January 14, 2016

Educational Issues facing Haywood County - February 11, 2016

Vision - March 17, 2016

State Government – Day-trip to Nashville - date TBD

Graduation - April 21, 2016

All students must attend at least one session of each of the following community board meetings:

City of Brownsville or Stanton City Board, Board of Education, and Haywood County Commission; therefore, a total of attending three meetings is required.

5. Community Analysis

Please identify a particular challenge, issue, or problem you feel is critical to Haywood County. Explain your concerns and possible involvement in the solution.

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

In your opinion, in what areas is Haywood County strong?

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

6. References- Please list the name, address and phone number of two references that know you.

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

7. Tuition

Tuition for Leadership Haywood County is $

400.00

. Upon acceptance to the program, tuition must be paid in full

no later than September 1st.

I understand the financial and attendance requirements to participate in Leadership Haywood County, and agree to abide by them if selected to participate as a class member.

_______________________________________________

Signature

___________________________

Date

Mail or take form to: Brownsville-Haywood County Chamber of Commerce

121 West Main Street

Brownsville, TN 38012

Download