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Signature Adult Program Application
About You:
Name
*
First Name
Last Name
Name as it should appear on nametag/preferred name:
*
Address
*
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Cell Phone Number
*
Personal Email
*
Verify Email
*
Birthdate
*
mm/dd/yyyy
Which race or ethnicity best describes you?
*
At Leadership Geauga, we ask about an individual’s ethnicity because we value diversity in programs.
American Indian or Alaskan Native
Asian/Pacific Islander
Black or African American
Hispanic
White/Caucasian
Multiple Ethnicities/Other (please specify)
Other
Dietary Restrictions
How did you learn about Leadership Geauga?
*
Friend or Family Member
A Leadership Geauga Alumni
Social Media
Newspaper/magazine
Community Event/Taste of Leadership
Leadership Geauga's Website
Other
Friend or Family Member's Name
Other
Have you applied to Leadership Geauga's Signature Adult Program in the past?
*
select one
Yes
No
If applicable, list family members who have completed a Leadership Geauga program:
Employment Information
Current Employer
*
What is your business/employer type?
*
select one
Sole Proprietor
Non-profit Organization
Corporation (INC)
Limited Liability Company (LLC)
Other
Other
Employer Address
*
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Your Title:
*
Your Business Email Address
*
Verify Email
*
Your Business Phone Number
*
Most recent former employer
Education/Military
Please enter the highest level of education completed, including degree
select one
High School/GED
Associate Degree
Bachelor's Degree
Master's Degree
Advanced/Professional Degree
Military Service
Other
Field of study (if applicable)
Example: B.A. in Business, M.B.A., etc.
General Questions
What are your long-term goals as a leader, and how do you plan to develop yourself to achieve those goals?
*
Why is community involvement important?
*
Program Committment
Class members are expected to participate fully in program activities:
*
A. Orientation Day - full day B. Weekend Retreat - two days with an overnight stay C. Ten full-day program days. Please note: Graduation Day is a full day and evening. A minimum of 80% attendance is required for graduation. D. Each class member participates in a team which requires an average of six meetings. Please read and check the following statements to indicate your commitment:
My employer supports the time required for participation
My family supports the time required for participation
If selected for the program, I will devote the time required
Tuition Requirement
*
The tuition for each participant in Leadership Geauga is $2,500 of which $150 must be paid by the individual. How will the remaining $2,350 be paid (Personal? Employer? Other?)? A portion of tuition must be paid before Orientation. All tuition payments are nonrefundable.
Personal
Employer
Other
I am interested in a tuition payment plan
I am interested in scholarship assistance
Why are you requesting a scholarship?
*
Tuition is $2500. What amount of tuition are you requesting?
*
How would you pay the remainder of the tuition? Would your employer be covering a portion? Would you personally be covering a portion? What would the percentage look like?
*
Other
Ground Rules for Participation:
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We are diverse: I will respect other's beliefs, politics, needs, and styles.
I understand that Leadership Geauga is a safe place to gather with your peers and develop personally and professionally while learning more about our beautiful county; it is not a place to push politics and religious beliefs.
I will not use cell phones in class. I understand the Executive Director's cell phone number will be given out and is to be used for emergencies.
I will listen and share ideas. If I am a talker, I will try to listen more. If I am quiet, I will try to speak up more.
I will attend every Leadership Geauga program day and be there for the entire day (generally from 8:00 a.m. to 6:00 p.m.).
I will fully participate on my planning team, which will meet six times to plan our issue day.
I understand that Orientation and Retreat are mandatory.
I understand to graduate Leadership Geauga, I cannot miss more than two class days.
I will serve as a resource and support to my fellow class members
On occasion, I may be required to prepare ahead of time for a class day and will complete this assignment to the best of my ability.
I understand that in facing these realities of the county, not all of my experiences will be pleasant and pretty. But I am committed to learning more about our county.
I will make a payment towards my tuition before Orientation
I understand that tuition is non-refundable
