Please give us some basic demographic information:

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* 1. Please give us some basic demographic information:

Please give us some information about your current employer.

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* 2. Please give us some information about your current employer.

AGE: Completing this question is voluntary. It will remain confidential and will only be used to ensure the diversity of the class.

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* 3. AGE: Completing this question is voluntary. It will remain confidential and will only be used to ensure the diversity of the class.

RACE/ETHNICITY: Completing this question is voluntary. It will remain confidential and will only be used to ensure the diversity of the class.

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* 4. RACE/ETHNICITY: Completing this question is voluntary. It will remain confidential and will only be used to ensure the diversity of the class.

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:

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* 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:

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:

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* 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:

Please check all that apply:

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* 7. Please check all that apply:

Please tell us if you require any special accommodations or have dietary restrictions.

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* 8. Please tell us if you require any special accommodations or have dietary restrictions.

What specific skills or knowledge do you hope to gain from your participation in Leadership Tompkins?

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* 9. What specific skills or knowledge do you hope to gain from your participation in Leadership Tompkins?

What unique perspective or personal experience do you feel you can contribute to the class?

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* 10. What unique perspective or personal experience do you feel you can contribute to the class?

Why do you want to learn more about leadership in Tompkins County?

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* 11. Why do you want to learn more about leadership in Tompkins County?

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:

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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:

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.

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* 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.

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.

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* 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.

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