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Leadership Tompkins Application for 2018-19 Class
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1.
Please give us some basic demographic information:
(Required.)
First Name
Last Name
Cell Phone Number
Email Address
Home Address
Home City, State, Zip
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2.
Please give us some information about your current employer.
(Required.)
Company/Organization
Job Title
Supervisor Name
Work Address
Work City, State, Zip
Work Phone
Work Email
How long in current role?
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+
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):
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):
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:
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.
8.
Please tell us if you require any special accommodations or have dietary restrictions.
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9.
What specific skills or knowledge do you hope to gain from your participation in Leadership Tompkins?
(Required.)
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10.
What unique perspective or personal experience do you feel you can contribute to the class?
(Required.)
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11.
Why do you want to learn more about leadership in Tompkins County?
(Required.)
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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:
(Required.)
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)
13.
If your employer is covering all or part of the fee, please provide contact information for the person in your organization that should receive the invoice for the program.
**NOTE: Payment due in full by the October 11 program date.
Billing Contact
Billing Email
Billing Address
Billing Phone
*
14.
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.
(Required.)
Yes
