January 13, 2017 - Deadline for application and $50 application fee

Personal Information:

Full name:

How you would like your name on your name tag:

Title:

Employer:

Business Mailing Address:

Business Mailing City/State/Zip:

Business Phone:

Work email: Personal email:

Cell/Alternate Phone:

Food Allergies/Dietary Restrictions:

Physical Restrictions:

Fleece Size (men’s): XS, S, M, L, XL, XXL

Personal Statement:

Each program year we try to customize the content of the program based on the interests of the participants. Please use an additional sheet of paper to answer the following questions:

1. What are the reasons you want to participate in the Leadership A2Y 2.0 program?

2. Have you attended any previous leadership training seminars, courses or programs? Please list all.

3. Are you currently in a leadership position in your place of employment and/or community? Please list all.

4. What issues do you and/or your organization face in terms of leadership?

Tuition and Application Fee:

The tuition for the Leadership A2Y program is $2,500 for Chamber Members and $3,000 for Prospective Chamber Members. The tuition covers program costs for books, assessments andthe six monthly sessions, including meals. In addition to tuition, there is a $50.00 non-refundable application fee.

Commitment:

Leadership A2Y requires commitment, prioritization and dedication. Each participant is required to attend every session. If a class member is absent in excess of one (1) session, they forfeit their eligibility to graduate. The day and half retreat on January 24thand 25thwill be mandatory attendance.

Cancellation Policy:

An applicant’s place is secured in the class as soon as he/she is notified in writing of his/her acceptance, and when tuition is paid in full. Applicants are encouraged to sendpayment with their applications. Full tuition payment is due byJanuary 24, 2017.

If payment is not received, or if arrangements to makenecessary payment(s) are not made with the Chamber, the applicant’s place in the classwill not be secured and may be given to another. If an applicant must cancelor forfeits his/her place within the class, a $100 cancellation fee will be charged at thediscretion of the A2Y Regional Chamber. If an applicant cancels within10 days prior to the Retreat, one-half of the full tuition will be forfeited. If an applicant cancels after the Retreat, the entire tuition will be forfeited and no refunds will be granted. Thank you foryour understanding.

I understand the attendance, payment, and cancellation requirements of the Leadership A2Y2.0 program. If selected, I will pay the tuition.

Signature: ______Date: ______

We would be pleased to provide you with additional information should you have any questions or concerns. Please contact Barbara Davenport at 734.214.0104 or .

Send completed application along with Tuition and the $50non-refundable Application Feeto:

Chamber Member
Application Fee / $50
Tuition / $2,500
Total / $2,550
Prospective Member
Application Fee / $50
Tuition / $3,000
Total / $3,050

Leadership A2Y2.0

A2Y Regional Chamber

115 West Huron Street, 3rdFloor

Ann Arbor, MI 48104-2303

Or

Or Fax: 734.665.4191

Method of Payment

?Check, payable to the A2Y Regional Chamber

?Visa ______

Credit Card Number/Expiration Date/3 Digit Security Code

?MasterCard ______

Credit Card Number/Expiration Date/3 Digit Security Code

?American Express ______

Credit Card Number Expiration Date/5 Digit Security Code

?Discover______

Credit Card Number/Expiration Date/3 Digit Security Code

Signature:______Date:______