Application – Leadership Unlimited

Personal Information

Full Name *

Preferred Name

Preferred Pronouns

Gender *

Personal Email *

Mobile Phone *

Home Address *

City *

State *

Zip Code *

Emergency Contact Name *

Emergency Contact Relationship to You *

Emergency Contact Phone *

Leadership Unlimited is designed for participants who live OR work in Richland County. Please select your status below. *I live in Richland County.I work in Richland County.I both live and work in Richland County.

How many years have you lived in Richland County? *

How many years have you worked in Richland County? *

Employment

Current Employer

Title and Responsibilities

How many years have you worked in this role?

Supervisor Name

Work Email

Work Phone

LinkedIn Profile

Work Address

City

State

Zip Code

Other Organization

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

Position/Title

Organization Contact Name

Address

City

State

Zip Code

Leadership Unlimited Information

Briefly describe your interest in Leadership Unlimited, what you hope to gain, and how you expect to utilize your program experience. *

What makes you a compelling candidate for this program? Please consider your leadership experience and/or future plans and goals, both professionally and in the community. *

What does the word "leadership" mean to you? *

Please give an example of an impactful use of leadership skills, either that you executed or that you observed in someone else. *

Please give your opinion of three significant opportunities and/or challenges facing Richland County. *

References

Please list the names and emails of three references. They will be contacted to complete a reference form.

Current Supervisor (preferred) or Professional Reference

Name *

Company *

Email *

Phone *

Personal Reference

Name *

Company *

Email *

Phone *

Someone familiar with your community and leadership activities.

Name *

Company *

Email *

Phone *

Commitment

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

Opening icebreaker event (optional)
Opening Retreat at Camp Nuhop Hemlock Campus: Friday, September 15-Saturday, September 16, 2023 (no absence)
One full weekday per month, the second Thursday, October through June, (up to two absences permitted)
Planning sessions (time set at the convenience of program planning committee)
Capstone project (8-10 hours throughout program)
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

Finance

Tuition for the Leadership Unlimited program is $1,500. Discounts apply for Catalytic Members of the Richland Area Chamber & Economic Development. A non-refundable deposit of $250 is due when the candidate returns the acceptance form. The remainder of tuition is due by September 29, 2023, 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.

Who will pay your tuition?My employer will pay my tuition.I will personally pay my tuition.My tuition will be paid through a combination of employer and personal funds.

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

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.

Signature *