Application – Leadership Unlimited

Personal Data

Full Name *

Nickname

Email *

Phone

Home Address

City

State

Zip Code

How many years have you lived in Richland County?

How many years have you worked in Richland County?

Employment

Company

Phone

Address

City

State

Zip Code

Present Responsibility

How many years have you been at this position?

Name of individual to whom you report

Title

Other Organization

Please complete the following questions if you are representing an organization other than your place of employment.

Sponsoring Organization

Position/Title

Address

City

State

Zip Code

References

(Please send a Reference Sheet to each individual and have them mail the completed sheet to Leadership Unlimited.)

Representative of sponsoring organization (CEO or immediate supervisor)

Name

Address

City

State

Zip Code

Phone

Personal reference

Name

Address

City

State

Zip Code

Phone

Someone familiar with your community and leadership activities

Name

Address

City

State

Zip Code

Phone

Leadership Unlimited Data

Please give your opinion of 3 significant opportunities and/or challenges facing the Mansfield/Richland County community.

Commitment

To graduate from Leadership Unlimited, a participant must meet these attendance requirements:

Opening icebreaker event (optional)
Opening conference: Friday-Saturday retreat (no absence)
One full weekday per month, October through June, (the second Thursday)
Planning sessions (time set at the convenience of program planning committee)
Final dinner celebration at the conclusion of the program.

Will you be able to fulfill this time commitment?YesNo

Do you have the full support of your employer for the required time-off from your position?YesNoNot Applicable

I understand the purposes of the Leadership Unlimited program and, if I become a participant, I will devote the time and energy necessary to make it a successful experience and will use this experience to develop my leadership skills in the community.

Finance

Who will pay your tuition? (If combination, indicate percentages)

Tuition for the Leadership Unlimited program is $1,500. A non-refundable deposit of $250 is due when the candidate returns the acceptance form. The remainder of tuition is due by September 10 unless special arrangements are made. Limited tuition assistance is available and is considered only after an applicant is selected for the program. The need for tuition assistance is not a consideration for selection for the leadership program.

Personally

Employer

If accepted in the Leadership Unlimited program, do you wish to apply for Tuition Assistance?YesNo