* 1. Contact Information

* 2. Add'l Contact Information

* 3. Please describe your personal background:

* 4. Please describe your professional background:

* 5. Please describe your civic background:

* 6. Why do you want to be in this leadership program?

* 7. What are your expectations for this course?

* 8. Describe your current leadership skills and/or goals:

* 9. Henry County Participation

* 10. 2015 Program Schedule

August 19, 2014 - Class of 2015 Kick Off (Evening)
September 4-5, 2014 - Class Retreat
October 22, 2014 - Local Government Day
November 12, 2014 - Education Day
December 10, 2014 - Economic Development/Tourism Day
January 14, 2015 - Community/County Day
February 11, 2015 - State Government Day
March 18, 2015 - Healthcare Day
April 18, 2015 - Hands on Henry
April 29, 2015 - Public Safety Day
May 12, 2015 - Graduation (Evening)

Please check next to each box, if you understand and agree to each of the following about the program:

T