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1. By signing my full name and dating below, I confirm that the information I provide hereafter is accurate and true. (Required.)

PERSONAL INFORMATION

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2. First Name (Required.)

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3. Last Name (Required.)

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4. E-mail address (Required.)

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5. What is your home street address? (Required.)

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6. What is your city, state, zip? (Required.)

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7. Mobile Phone Number (Required.)

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

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9. Date of birth (Required.)

Date

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10. What is your gender identity? (Required.)

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11. Race (Required.)

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12. Name of the local community leadership development program(s) in which you have participated. Completion of a local community leadership development program or comparable experience is a prerequisite of Community Leadership 2.0 participation. (Required.)

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13. Tuition for participants in the second year of the Community Leadership 2.0 cohort model is discounted at a rate of $1950. How do you plan to cover the cost of tuition?

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14. Scholarships may be available for qualified applicants who demonstrate a strong commitment to the program and who may need financial assistance to participate. Would you need scholarship funds in order to participate?

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15. If you are requesting scholarship funds, please describe your need.

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16. Special Requirements: dietary, physical or other

EDUCATIONAL BACKGROUND

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17. Post-Secondary School

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18. Graduate School - School and Area of Study

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19. Other Education, Training or Certification

EMPLOYMENT INFORMATION

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20. Current Employer (company/organization) (Required.)

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21. Employer Address (Street, City, State, Zip) (Required.)

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22. Length of time employed by current employer (Required.)

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23. Name of Immediate Supervisor (Required.)

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24. Email Address of Immediate Supervisor (Required.)

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25. Phone Number of Immediate Supervisor (Required.)

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26. I hereby verify that my immediate supervisor and/or employer have received information about the requirements of participation in Community Leadership 2.0 and support my participation in the program.
Please sign and date below to confirm the above statement.
(Required.)

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27. Previous employers since 2020, if any

PROFESSIONAL & COMMUNITY ENGAGEMENT

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28. 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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29. 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.

LEADERSHIP DEVELOPMENT REFERENCE

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30. Name of nominator or reference who could speak to the demonstration of your leadership capacity. (Required.)

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31. Relationship to Nominee (Required.)

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32. Nominator/Reference Email Address (Required.)

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33. Nominator/Reference Contact Phone Number (Required.)

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34. How did you learn about Community Leadership 2.0?

ESSAY QUESTIONS

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

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35. In your opinion, what are the most critical issues facing your local community? (Required.)

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36. 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 Community Leadership 2.0 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 cohort. (Required.)

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37. What do you most wish to obtain from the Community Leadership 2.0 experience? (Required.)

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38. What, if any, connection do you have to the focus topic for this year's Community Leadership 2.0 cohort - Housing? (Required.)

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39. What aspirations do you have for yourself in terms of future community leadership roles and impact? (Required.)

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

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41. Your Title/Job/Role (Required.)

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