Leadership Macomb, Inc. · LM Application XXVII 2024-2025

Personal Information

Name

*

Prefix

First Name

Last Name

Suffix

Preferred Name or Nickname

*

Middle Name

*

Mobile Phone

*

Personal Email

*

Verify Email

*

Work Email

*

Verify Email

*

Preferred Email

*

Which email would you like us to use to communicate with you?

Personal

Work

Home Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Date of Birth

*

(mm/dd/yyyy)

Do you currently have a military ID (provides access to US military installations)?

*

Yes

No

If you do not have a military ID, please provide your Driver's License Number

Necessary to access secure locations.

Please provide your Driver's License Expiration Date

Necessary to access secure locations.

Driver's License State of Issuance

Emergency Contact Name

*

Emergency Contact Phone

*

County in which you currently reside

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Macomb

Oakland

Wayne

St. Clair

Genesee

Ethnicity

*

Please indicate your ethnicity (ethnicities)

Asian Pacific

African American

Caucasian

Hispanic

Native American

Middle Eastern

Wish not to disclose

Other (please explain)

Other ethnicity

Do you have any special dietary needs or will you require special accommodations?

*

Yes

No

If yes, please describe.

Work Information

Employer

*

Job Title

*

Work Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Business Phone Number

*

Number of Years with Employer

*

County in which you are currently employed (majority of business conducted in)

*

Professional Associations

Please list the Organization, the Position held and the Date you held the position, if any.

Community Involvement

What do you consider your most important civic contribution and why? Please include applicable professional and/or civic awards or recognition you have received, if any.

*

General Information

What do you feel are three most significant challenges facing Macomb County?

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What do you feel are the three most significant strengths of Macomb County?

*

What "take-aways" do you hope to gain from your participation in Leadership Macomb?

*

I am being nominated by:

*

A graduate of Leadership Macomb

Self

Employer

Name of Leadership Macomb Graduate

First Name

Last Name

Email of Leadership Macomb Graduate

Verify Email

What persuaded you to apply for this program?

*

Encouraged by my employer to participate

Encouraged by a co-worker from my current employer

Encouraged by a friend or acquaintance outside my current employer

Leadership Macomb presentation at a civic or professional organization that I am involved with

Advertising in Social Media or eNewsletter

Other

Applicant Commitment

*

If selected as a participant of Leadership Macomb XXVII, I will attend at least 80% of the monthly sessions. I will also make every effort to attend other functions sponsored by the program. I agree to respect and abide by the rules of host locations throughout the program. I understand that if I fail to meet any or part of this commitment, I may be asked to withdraw from the program without any refund of tuition. I understand that any false information may disqualify me from participation.

I agree

I am unable to agree at this time

Photo Release Consent

*

I do hereby give Leadership Macomb Inc. the right to use my name or photograph in all forms of media (print or electronic) or for any other lawful purposes. I also waive any right to inspect or approve the finished product, including written copy that may be created therewith. I understand and accept the commitments expected of me by Leadership Macomb.

I agree

I do not agree

Payment (Check all that apply)

*

Tuition for Leadership Macomb XXVII is $3,600 and covers all program and material costs and one ticket to Commencement. Tuition must be paid in full 60 days from the date of acceptance to the program, unless other payment arrangements have been made. A limited number of financial need-based scholarships are available to qualified individuals who may not otherwise be able to participate. Call 586-954-2788 to request a scholarship form. Cancellations are subject to a $200 materials fee. Cancellations must be made in writing to Leadership Macomb no later than 30 days in advance of the first session to receive a full refund (less $200 materials fee). Cancellation after this date will be subject to refund as follows: 29-15 days- 80%, 14-7 days- 50%, 6-0 days- no refund.

My employer is sponsoring my tuition

I am paying my own tuition (payment plans are available upon request)

I am applying for a scholarship

Supervisor's Name and Title

If your employer is sponsoring your tuition, please provide your supervisor's name and title.

Supervisor's Email

Verify Email

Your Signature

By entering your name here, you agree to the payment terms listed above.

*

Would you like to subscribe to our monthly eNewsletter?

Please subscribe me to your mailing list. I understand that I can unsubscribe at any time

Please upload your head shot or send to Julie at jpetkoff@leadershipmacomb.org

Consider Sponsoring a Junior Leadership Macomb Student

Participants, since 2013 over 350 students have graduated from Junior Leadership Macomb (JLM). The program costs $550 for each student to attend, but Leadership Macomb collects only a $200 registration fee from families to offset the cost. We are proud to have never turned away a student because of financial need. We give scholarships to an average of ten students each program year.

Please consider donating $200 to help a JLM student by going to our Donate Page https://leadershipmacomb.org/donate/.Thank you in advance for your consideration!