Core Program Application (Deadline is August 31, 2012)
Applicant Information
Full Name:
Date:
Last
First
M.I.
Home Address:
Street Address
Home Phone
City
State
ZIP Code
Social Security Number
Cell Phone:
Personal E-mail
Employer Name
Sponsor
Title
(if different than employer)
Employer Address:
City
State
Employer Phone:
Something interesting about yourself.
ZIP Code
Employer Email:
Personal Data: ( completing the following section is voluntary but not required).
Please place an “x” in the appropriate boxes below:
Age Range
Under 25
25-30
31-40
41-50
51-60
60+
Ethnicity
African American
Gender
Male
Asian/Pacific Islander
Caucasian
Hispanic/Latino
Other
Female
Please answer the following questions.
Do you have any special physical needs for which you are requesting accommodation? If yes, please describe:
Do you have any special needs (dietary, physical, etc.) for which you are requesting accommodation? If yes, please
describe:
Education
High School
From:
Did you
graduate?
To:
College
From:
To:
From:
To:
Did you
graduate?
Did you
graduate?
To:
Address:
Did you
graduate?
Trade/Other
From:
Degree:
Degree:
Degree:
Please place an “x” in the appropriate boxes below: How did you hear about Leadership Berks?
Leadership Berks Graduate
Attended a Leadership Berks Event
My Employer
Greater Reading Chamber of Commerce & Industry
Alvernia University
Other (please specify)
References
Please list three professional references.
Full Name:
Relationship:
Employer:
Ph:
Address:
Title:
Email:
Full Name:
Relationship:
Employer
Ph:
Address:
Title:
Email:
Full Name:
Relationship:
Employer:
Ph:
Address:
Title:
Email:
Professional and/or Personal Achievement
Please list any professional organizations or affiliations.
What do you consider the highest responsibility, skill, career or professional achievement to date?
Previous Employment
Company/ Organization:
Supervisor’s Title:
Address:
Job Title:
Responsibilities:
Supervisor’s Name:
Supervisor’s Title:
Supervisor’s Email:
Phone:
May we contact your previous supervisor for a reference? Please answer yes or no.
Expectations/Interests for Community Placement Requirement
Answers in the following sections will be summarized and provided to instructors so they may adjust their course
material to enrich your Leadership Berks experience.
Board and /or Committee Experience
Please answer yes or no to the following questions.
Have you served on a nonprofit board?
Have you served on a nonprofit committee?
If you have served on a board or committee in the past, please continue below. If not, skip to the next section.
Organization Name:
Mission:
Type of Position:
Describe Role:
From/To:
Contact Name:
Address:
Contact Phone:
Others? Please describe
Contact Email:
Unique Skills & Expertise
The following skills or abilities make me unique as a volunteer, board or committee member:
I speak the following languages fluently (other than English):
I have the following certifications: (i.e., CPR, First Aid, CPA, etc.)
Public Service & Community Engagement
Please answer questions by placing an “x” in the appropriate box below.
After Leadership Berks, I anticipate my contribution to a board or committee in hours/month will be:
1-5 hours
6-10 hours
11-15 hours
15-20 hours
20 + hours
Please place an “x” in the box that best describes the “level” or type of board or committee you think you will be ready
to serve upon completion of the program.
“governing board” – predominantly policy setting/decision making
“working board” – (hands on, volunteer tasks often assisting with day to day operations if necessary
“ad-hoc” committee – (specific task for a set time period or one-time event or task)
“board” committee – (year-round work within board term often from brainstorming to implementation)
Please place an “x” in any of the following categories in which you would like to serve after you complete
the Leadership Berks program. These will help us help you narrow down your interest areas.
(Categories provided courtesy of the United Way of Berks County.
Infants / Preschoolers (0-4)
Children (5-12)
Adolescent (13-17)
Nursing Homes
Young Adults (18-25)
Older Adults (55+)
Families / Parents
Disabled / Ill
Older Adults (55+)
Low Income/Poverty
Homeless
Minorities
Military
Men
Students
Women
The following categories best describe my interests:
Abused / Battered
Arts/Culture
Disabled / Ill
Disaster Victims
Homeless
Law Offenders
Literacy
Poverty
Recreation
Rural
Sexual Assault
Substance Abuse
Teen Pregnancy
Transportation
Technology
Urban
As an applicant for the Core Program, I place an “x” here
to indicate that I have read and reviewed
the following questions which are provided by Leadership Berks in conjunction with our Faculty of
Advisors to help you maximize your experience throughout the program and to pinpoint critical
questions you ought to consider as you prepare to identify your nonprofit board or committee service.)
General Questions
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Am I passionate about the mission of the organization for which I would like to serve as a board or
committee member?
Do I understand my legal, fiduciary, oversight responsibilities of being a board member?
Can I imagine making the organization one of my leading philanthropies to which I give of my time, energy,
and financial resources? Am I expected to make a contribution of a specific amount?
How will I contribute skills, or expertise to help advance the organization’s mission? Will I raise money?
Am I willing to introduce others to the work of the organization?
Are my goals the same as those of the organization and its board?
Do I have the time to make a meaningful contribution to the organization?
Self Defense Questions
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Is the organization incorporated?
What is its tax status?
Are the bylaws current? Are they Sarbox compliant?
Is there D&O coverage?
What is the relationship (if any) between this entity and any national/parent entity?
Is there any pending litigation by or against the organization that could materially affect its fiscal health?
Is there an audit?
Are there written human resources policies and procedures for hiring?
Best Practice Questions
Governance
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Is there a power limit for the executive committee? If so, what is it?
What is the size of the board and its composition? How is it selected?
Is there a job description or written expectations for board members?
What percentage of the board is independent? What is the nature of existing conflicts of interest?
Are any board members compensated by the organization?
What are the term limits?
What has the board done about voluntary compliance with relevant Sarbox provisions?
Does the organization seek to exist in perpetuity or for some other time horizon? Has that been articulated?
Under what circumstances would the organization go out of business?
Finance and Risk
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Describe the audit process, auditor selection and the board review process of the audit?
What known risk exposures have been identified and how are they managed?
What is the composition of revenue? What risks may that pose?
Who are our competitors? What is our competitive advantage, what is theirs?
What is the status of our strategic plan?
Are there succession plans in place for key staff and volunteers?
Fundraising
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Is there a gift acceptance policy in place?
Is there a naming rights policy in place?
Does the organization have written cultivation plans in place for its top 25 prospects?
What percentage of contributions comes from special events? Planned giving? What is the long
term strategy for private philanthropy?
How is the professional fundraising staff member compensated?
What is the role/expectation of board members in fundraising?
Is there an endowment, what is its purpose?
Are there donor directed gifts as part of this endowment?
Greater Reading & Berks County Perspective
In 200 words or less, please describe the three most significant problems or challenges you see facing
Greater Reading and Berks County now and in the next 10 years. Explain your choices and offer any
recommendation for action you may favor for each.
Expectations
Please explain briefly what you hope to gain from, and how you expect to use, your Leadership Berks
experience to meet your personal and professional goals.
By placing an “x” here,
2011-2012 Proposed Session Dates & Important Deadlines
I indicate that I have blocked the following dates on my calendar
and
understand that all sessions are mandatory unless requests are made in writing at the time of
application to the Director (dates in bold are non-negotiable). Requests will be considered case-bycase and approved at the sole discretion of the Director. Session dates or times are subject to change.
Program Orientation
Two-day Overnight Retreat
November
December
January
February
March
April (Session & Social)
May & Project Presentations
June (Graduation & Luncheon)
7:45am-12Noon, Thurs., Sept. 20th
7:30am Thurs., Sept. 27th- 4:30pm, Fri, Sept. 28th
8am-5pm, Thurs., Nov. 1st; Reception 5-7pm
8am-5pm, Thurs., Dec.6th; Reception 5-7pm
8am-5pm, Thurs., Jan.10th (weather backup Jan 17th)
8am-5pm, Thurs., Feb. 7th (weather backup Feb. 14th)
8am-5pm, Thurs., Mar. 7th (weather backup Mar.14th)
8am-5pm, Social 5pm-7pm, Thurs, Apr. 11th
8am-5pm, Thurs., May 2nd
10am-3pm, Thurs., Jun. 6th
2012-2013 TUITION
(Unless noted otherwise on this application or unless arrangements have been
made in writing in advance, please enclose payment.)
Employer Sponsored Rate: $2520.00
Discount Rate: $2060.00
(The discount rate is available to self-sponsored applicants or employees of nonprofit organizations with an annual
operating budget under $250,000. Budget must accompany this application.)
Please note the party responsible for payment of the tuition will be noted as the applicant’s sponsor in all of
Leadership Berks’ publications before, during and after participation in the program.
Please make check payable to: Leadership Berks at Alvernia University
Please place an “x” on the appropriate box below.
I am an employer-sponsored applicant. Please bill my employer upon acceptance.
I am an individual applicant sponsored by an organization other than my employer.
(i.e. service club or association).
I am an employer sponsored applicant with an annual operating budget under
$250,000 eligible for the discounted rate. (Budget must be attached to qualify.) Please
bill my employer upon acceptance
I am a self-sponsored applicant eligible for the discounted rate. Please bill me upon
acceptance
I am an individual requesting consideration for a scholarship. Enclosed is my letter to
the Scholarship Review Committee explaining the nature of my request and what
portion of the tuition, if any, I am willing to pay. Preference is given to partial
scholarship requests..
SCHOLARSHIP APPLICANT’S PLEASE NOTE THE FOLLOWING:
Depending on available resources, Leadership Berks may award scholarships to
individuals who are self-sponsored or who work for a nonprofit organization with
an operating budget under $250,000. All requests must be made in writing
addressed to the Leadership Berks Scholarship Review Committee and must
accompany this application to be considered. Each request is reviewed on a case by
case basis. Preference is given to requests whereby the applicant or their sponsor
contributes a minimum of 50% toward tuition. Application for consideration is in no way
a guarantee of award.
Party responsible for tuition payment:
NAME:
ADDRESS:
TITLE:
PHONE:
EMAIL:
Photo Release
I,
give the Leadership Berks Program and Alvernia University absolute right and permission to use photographs of
me in its promotional materials and publicity efforts. I understand that the photographs may be used in publications, print
ads, direct-mail pieces, electronic media (e.g. video, CD-ROM, internet/WWW), or other forms of marketing and
promotions. I release Leadership Berks, Alvernia University, any photographer, their offices, employees, agents, and
designees from liability for any violations of any personal or proprietary right I may have in connection with such use.
Applicant/Employer/Sponsor Work Release & Support
By placing and “x” here
and by signing below, I and my employer, sponsor, or supervisor fully support my participation
in the Leadership Berks program including release from work to attend sessions, meetings or events related to the
program in whole or in part, without penalty. I, my employer, sponsor or supervisor agrees to meet all program
expectations and requirements associated with participation including but not limited to: monthly class sessions, class
projects, and service learning projects; and to fulfill all requirements associated with the terms of my placement with a
board or committee position for a minimum of one year as required post program completion. More specifically, to fully
engage with and support program requirements including but not limited to:
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Attending and actively participating in the Core Program ½ day orientation
Attending and actively participating in mandatory two-day overnight retreat
Attending and actively participating in all full-day, monthly sessions. Prefer to no class time is missed however the
maximum allowable excuse hours is 16 over the course of the entire program.
Assigned by Leadership Berks to project team and meet in & out of class as needed to meet project objectives
Securing an initial meeting with the project team and beneficiary
Actively working with a class team throughout the program with completion and deliverables
Attending and actively participating in meetings for service learning projects throughout the program
Actively working on a class committee during the course of the program
Actively working with members of the class to identify a class community service project or drive
Attending and actively participating in class committee meetings during the course of the program
Attending and actively participating in post-session evening receptions during the course of the program
Attending and actively participating in and helping to plan Alumni Council events
Identifying and confirming a committee or board position with a min. term of 1year after the program is the sole
responsibility of the participant. Some assistance is available through Leadership Berks upon request by April 1st
Identify incoming class participants and invite them to attend the Spring Social
Determine with classmates an individual/class financial donation back to Leadership Berks by May 1st
Attending Service Learning Project Presentations at May Capstone Class Session
Attend graduation in June
Upon acceptance into the program, Leadership Berks reserves the right to dismiss any
person who fails to comply with participation guidelines or who fails to meet program
requirements or expectations in or out of the classroom. Any person dismissed from the
program or their sponsor will not be eligible for a tuition refund of any kind.
Applicant’s Name
________________________________________________
Applicant’s Signature
__________________
Date
Supervisor’s Name (if sponsored by employer)
_______________________________________________
Supervisor’s Signature
__________________
Date