Leadership Institute Application Form

Your Personal Information

Your Name

First Last

Your Email Address

Enter Email Confirm Email

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Your Phone

Affiliations

Present and/or past employment (if applicable)

Employer

Present Position

Retired?

Former Employer

Employer Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Organization

Responsibility

Why do you want to be a participant in the Jo Daviess Leadership Forum Leadership Institute.

A short essay outlining the two or three significant issues and challenges your community and county will face in the next ten years. Please include how you see your participation in the Jo Daviess Leadership Forum helping you to be involved in these issues.

Please Provide the following:

Commitment: To graduate from the Jo Daviess Leadership Forum, members are expected to commit the time to fully complete all aspects of the program by: attending both the opening retreat and each monthly day-long seminar, and interacting fully with other Forum participants.

Will you be able to fulfill this time commitment?

Yes

No

If no, please explain:

Has your employer, if any, agreed to allow you this time commitment?

Tuition for each participant is $1,500.00 plus books and materials fee of $500.00. After notification of acceptance, you will receive an invoice for the total two weeks following the opening retreat. You may arrange for payment to be submitted by your sponsoring organization. Scholarship assistance may be available. Major credit cards are accepted.

Sponsoring Organization, if any:

I understand the purpose and commitments of the Jo Daviess Leadership Forum, and if I become a participant, I will devote the required time and be responsible for the tuition.

Applicant’s Signature

Date

Information

Tuition & Financial Aid

College Readiness

Programs

Programs

Student Resources

Campus

Community

Ensembles

Tickets

Jo Daviess Leadership Forum Application Form

Your Personal Information

Affiliations

Please Provide the following: