Leadership Tompkins Registration for 2017-18 Class Question Title * 1. Please give us some basic demographic information: First Name Last Name Cell Phone Number Email Address Home Address Home City, State, Zip Question Title * 2. Please give us some information about your current employer. Company/Organization Job Title Supervisor Name Work Address Work City, State, Zip Work Phone Work Email How long in current role? Question Title * 3. AGE: Completing this question is voluntary. It will remain confidential and will only be used to ensure the diversity of the class. 21-29 30-40 41-50 50+ Question Title * 4. RACE/ETHNICITY: Completing this question is voluntary. It will remain confidential and will only be used to ensure the diversity of the class. Asian Bi-Racial/Multi-Racial Black/African-American Latino/Hispanic Native American White Other, not listed (please describe): Question Title * 5. EDUCATION: Completing this question is voluntary. It will remain confidential and will only be used to ensure the diversity of the class.Check all that apply: High School Diploma Associate's Degree Bachelor's Degree Master's Degree Doctorate Other, not listed (please describe): Question Title * 6. GENDER: Completing this question is voluntary. It will remain confidential and will only be used to ensure the diversity of the class.I identify as: Question Title * 7. Please check all that apply: I live in Tompkins County. I work in Tompkins County. I went to college in Tompkins County. I was born in Tompkins County. Question Title * 8. Please tell us if you require any special accommodations or have dietary restrictions. Question Title * 9. What specific skills or knowledge do you hope to gain from your participation in Leadership Tompkins? Question Title * 10. What unique perspective or personal experience do you feel you can contribute to the class? Question Title * 11. Why do you want to learn more about leadership in Tompkins County? Question Title * 12. Financial Responsibility Statement: I understand that the cost of this program is $950. This fee covers all associated training materials, food costs, and other logistical fees. Please check with your employer before you complete this question to ensure your tuition coverage.Please let us know which is true below: My employer is covering the full cost of the fee. I am personally covering the full cost of the fee. I will need a scholarship to participate. (You will be directed to a scholarship application if you choose this option) Question Title * 13. I am aware of the time commitment involved in the program and agree to attend all sessions, as well as work with my employer to ensure that my participation in the program is a priority.I understand that if I fail to meet these commitments, I will not graduate from the program and am not eligible for a refund of my tuition. Yes Next