Stephenson County 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

Your Present Employer

Please list your previous employers, the dates you worked and the position you held

Employer

Present Position

Retired?

Former Employer

What are/were your major job responsibilities?

List the Community, civic, professional, business, religious, social, athletic and other organizations of which you are or have recently been a member. Also include any special awards or honors you may have received.

Organization

Responsibility

Awards/Honor(s)

Please Provide the following:

A short essay explaining why you want to be a participant in the Jo Daviess County Leadership Forum. Please include an indication of your personal goals in participating.

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 Leadership Forum helping you to be involved in these issues.

Commitment: To graduate from the Jo Daviess County 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. Full or partial scholarship assistance is readily available. Major credit cards are accepted.

Sponsoring Organization, if any:

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

Applicant’s Signature

Date

If employed, please have your employer sign below indicating support and commitment to this application.

Employer Signature

Date

Employer Address

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

Information

Tuition & Financial Aid

College Readiness

Programs

Programs

Student Resources

Campus

Community

Ensembles

Tickets

Stephenson County Leadership Institute Application Form

Stephenson County Leadership Forum Application Form

Your Personal Information

Affiliations

List the Community, civic, professional, business, religious, social, athletic and other organizations of which you are or have recently been a member. Also include any special awards or honors you may have received.

Please Provide the following: