Building Leaders for Our Community

CLASS OF 2016/2017 APPLICATION

BUILDING LEADERS FOR OUR COMMUNITY

The completed application must be received by July 1, 2016.

Name of Applicant:

Last First Middle

Home Address:

Street

City State Zip County

Home Telephone: Cell Phone:

Employer:

Position:

Business Address:

Business Phone:

Business Fax:

E-mail:

How did you hear about Leadership Carbon?

LEADERSHIP EXPERIENCE Page 2

A. Briefly describe any leadership roles and responsibilities you may have had (if any):

COMMITMENT TO SERVING THE COMMUNITY

A. In your judgment, what are the three most pressing issues facing Carbon County today?

(Explain why)

1.

2.

3.

B. How do you hope to contribute to Leadership Carbon?

C. Briefly describe what you hope to gain from Leadership Carbon.

PROGRAM / PARTICIPATION / SPONSOR SUPPORT

A. Participant’s Agreement / Class Attendance

Leadership Carbon requires the participant to attend half day seminars generally scheduled on the second

Wednesday of each month, September, 2016 through May, 2017 beginning with a pre-class evening mixer Thursday, September 8, 2016

As a participant, I am willing to attend all functions sponsored by the program and understand that absence from more than two sessions will result in dismissal from the program. Special circumstances will be reviewed on a case-by-case basis.

–––––––––––––––––––––––––––––––– –––––––––––––––––––––––––– –––––––––––––––––––– Signature Name (Please print) Date

B. Tentative Program Agenda Page 3

DATE / TIME / COMMUNITY PROFILE / LEADERSHIP SKILL
2016-Sept.8 / 4 p.m. / Mixer, Class Info, Non-Profits
Sept. 14 / 8:00am to 12:00pm / Education / DISC
Oct. 12 / 8:00am to 12:00pm / Environment / Volunteerism
Nov. 9 / 8:00am to 12:00pm / Media Day / Professional Etiquette
Dec. 14 / 8:00am to 12:00pm / Carbon Co. History / Time Management
2017
Jan. 11 / 8:00am to 12:00pm / K-9 Patrol/EMA / Team Building
Feb. 8 / 8:00am to 12:00pm / Economic Development/Chamber / Tourism/Leadership Skills
Mar. 8 / 8:00am to 12:00pm / Drug Task Force / Leadership Skills Part II
Apr. 12 / 8:00am to 12:00pm / Government / Leadership Skills Part III
May TBA / Graduation

C. Tuition

Cost for this nine-month leadership development course is $250 Early Bird registration by May 1, 2016, $297 after May 1 to July 1, 2016 (non-refundable). This covers all program costs. Travel is at your own expense.

Make check payable to CCEDC/Leadership Carbon.

Partial scholarships may be available.

D. Organization Support (Not applicable if self-employed or not employed)

Name of Organization:

Name of Supervisor: Title:

As the candidate’s supervisor, I certify that this candidate has my full support to participate in Leadership Carbon. I am aware of the time commitment necessary, as well as the financial obligation. I recommend this candidate because

Supervisor’s Signature:

Date:

E. Candidate Page 4

I understand the goals and commitment of Leadership Carbon. Notification of acceptance will be made by July 31, 2016. If selected, I will devote the required time and arrange for the payment of my tuition by August 31, 2016. I hereby affirm that all information included in this application is accurate.

Candidate’s Signature: Date:

F. Continuing Education Credits are available for interested participants. G. Deadline: Applications must be received by July 1, 2016.

Please return this completed form to:

Leadership Carbon

c/o Carbon Chamber & Economic Development Corporation (CCEDC)

137 South Street, Lehighton, PA 18235

Phone: 610-379-5000

E-mail:

Leadership Carbon is committed to equal opportunity and diversity in its membership.

Sponsored by