LEADERSHIP GREATER MADISON - LGM31 Application (2024/25) Survey

CONFIDENTIALITY NOTICE

Please note that your application information will remain confidential until official acceptance into the program. Upon acceptance, only your primary contact information will be distributed to program presenters and other members of the class. You will be notified of any other requests to share your contact information throughout the program year.

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* 1. By signing my full name and dating below, I confirm that I have read, understand, and agree to the Leadership Greater Madison Application Guidelines and Program Code of Conduct, and that the information I provide hereafter is accurate and true.

PERSONAL INFORMATION

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* 2. First Name

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* 3. Last Name

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* 4. E-mail address

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* 5. What is your street address?

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* 6. What is your city, state, zip?

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* 7. Mobile Phone Number

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* 8. Preferred Contact Phone Number (if different from mobile number provided above)

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* 9. Date of birth

Date (MM/DD/YYYY)

Date

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* 10. What is your gender identity?

Male

Female

Non-binary

Prefer not to answer

Prefer to self-describe:

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* 11. Preferred pronouns

She/Her/Hers

He/Him/His

They/Them/Theirs

Other (please specify)

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* 12. Race

American Indian or Alaska Native

Asian or Pacific Islander

Black or African American

Hispanic or Latino

White/Caucasian

Prefer not to answer

Prefer to self-describe

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* 13. Number of years you have lived or worked in the Greater Madison region

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* 14. Special Requirements: dietary, physical or other

EDUCATIONAL BACKGROUND

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* 15. Post-Secondary School

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* 16. Graduate School - School and Area of Study

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* 17. Other Education, Training or Certification

EMPLOYMENT INFORMATION

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* 18. Current Employer (company/organization)

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* 19. Employer Address (Street, City, State, Zip)

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* 20. Your Title/Job/Role

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* 21. Length of time employed by current employer

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* 22. Name of Immediate Supervisor

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* 23. Email Address of Immediate Supervisor

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* 24. Phone Number of Immediate Supervisor

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* 25. I hereby verify that my immediate supervisor and employer has received the mandatory dates of LGM30 and supports my participation in the program.
Please sign and date below to confirm the above statement.

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* 26. Previous employers since 2010, if any

PROFESSIONAL & COMMUNITY ENGAGEMENT

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* 27. Please list all business and/or professional affiliations.

Include name of organization(s), position(s) held, period of affiliation, and description of involvement.

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* 28. Please list all community involvement here (community, civic, religious, political, social, athletic, or other activities).

Include name of organization(s), position(s) held, period of affiliation, and description of involvement.

NOMINATOR INFORMATION

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* 29. Name of Nominator
If you are self-nominating, please write "Self-Nomination"

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* 30. Relationship to Nominee

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* 31. Nominator Employer and Role

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* 32. Nominator Email Address

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* 33. Nominator Contact Phone Number

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* 34. Are you eligible for a discount?

Yes (please describe)

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* 35. How did you learn about LGM?

ESSAY QUESTIONS

Please share your answer to the following questions in no more than 250 words per question.

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* 36. In your opinion, what are the most critical issues facing the Greater Madison area and why?

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* 37. We strive to develop a diverse class that is comprised of a variety of different leaders. Please describe what makes you a compelling candidate for LGM and tell us why you want to participate in the program. Consider how your unique blend of personality, skills, perspectives, and experiences - both professionally and in the community - would make you an asset to the program and the LGM31 cohort.

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* 38. What do you most wish to obtain from the LGM experience?

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* 39. What do you envision for yourself in terms of future community leadership roles and impact?

If you have not had time to become actively involved, what conditions have changed now to enable you to seek opportunities for community involvement?

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* 40. Please choose one of the following questions to answer:

What factors (positive or negative) have influenced your growth as a leader?

Every obstacle we face in life comes with an opportunity to learn something new. Describe a challenge you have faced, how you persevered, and what you learned from the experience.

Tell us about a person who has been a leadership role model for you and why they have impacted your leadership journey.

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LEADERSHIP GREATER MADISON - LGM31 Application (2024/25)

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* 1. By signing my full name and dating below, I confirm that I have read, understand, and agree to the Leadership Greater Madison Application Guidelines and Program Code of Conduct, and that the information I provide hereafter is accurate and true.

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* 2. First Name

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* 3. Last Name

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* 4. E-mail address

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* 5. What is your street address?

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* 6. What is your city, state, zip?

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* 7. Mobile Phone Number

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* 8. Preferred Contact Phone Number (if different from mobile number provided above)

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* 9. Date of birth

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* 10. What is your gender identity?

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* 11. Preferred pronouns

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* 12. Race

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* 13. Number of years you have lived or worked in the Greater Madison region

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* 14. Special Requirements: dietary, physical or other

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* 15. Post-Secondary School

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* 16. Graduate School - School and Area of Study

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* 17. Other Education, Training or Certification

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* 18. Current Employer (company/organization)

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* 19. Employer Address (Street, City, State, Zip)

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* 20. Your Title/Job/Role

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* 21. Length of time employed by current employer

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* 22. Name of Immediate Supervisor

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* 23. Email Address of Immediate Supervisor

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* 24. Phone Number of Immediate Supervisor

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* 25. I hereby verify that my immediate supervisor and employer has received the mandatory dates of LGM30 and supports my participation in the program.Please sign and date below to confirm the above statement.

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* 26. Previous employers since 2010, if any

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* 27. Please list all business and/or professional affiliations.Include name of organization(s), position(s) held, period of affiliation, and description of involvement.

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* 28. Please list all community involvement here (community, civic, religious, political, social, athletic, or other activities).Include name of organization(s), position(s) held, period of affiliation, and description of involvement.

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* 29. Name of Nominator If you are self-nominating, please write "Self-Nomination"

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* 30. Relationship to Nominee

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* 31. Nominator Employer and Role

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* 32. Nominator Email Address

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* 33. Nominator Contact Phone Number

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* 34. Are you eligible for a discount?

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* 35. How did you learn about LGM?

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* 36. In your opinion, what are the most critical issues facing the Greater Madison area and why?

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* 38. What do you most wish to obtain from the LGM experience?

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* 39. What do you envision for yourself in terms of future community leadership roles and impact?If you have not had time to become actively involved, what conditions have changed now to enable you to seek opportunities for community involvement?

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* 40. Please choose one of the following questions to answer:

* 25. I hereby verify that my immediate supervisor and employer has received the mandatory dates of LGM30 and supports my participation in the program.
Please sign and date below to confirm the above statement.

* 27. Please list all business and/or professional affiliations.

Include name of organization(s), position(s) held, period of affiliation, and description of involvement.

* 28. Please list all community involvement here (community, civic, religious, political, social, athletic, or other activities).

Include name of organization(s), position(s) held, period of affiliation, and description of involvement.

* 29. Name of Nominator
If you are self-nominating, please write "Self-Nomination"

* 39. What do you envision for yourself in terms of future community leadership roles and impact?

If you have not had time to become actively involved, what conditions have changed now to enable you to seek opportunities for community involvement?