Leaders for Geelong Program Application 2014page 1

LEADERS FOR GEELONG

2014-16 PROGRAM

APPLICATION

Leaders for Geelong Program Application 2014page 1

Application Process

  • Applications close on 30 May 2014.
  • Shortlisted applicants will be invited to attend an interview.
  • All applicants will be notified of the outcome by 30 June 2014.

Instructions and advice for applicants

Leaders for Geelong Program Application 2014page 1

  • Please complete your application on this form by typing in the spaces provided.
  • Complete each section in full.
  • Applications must be signed by both the candidate and the employer, where applicable.
  • Individuals may nominate themselves.
  • Participation in the Leaders for Geelong program requires a significant time commitment over two years.Applicants must be able to meet the participant time commitment as detailed in the Participant Commitment section of this application form. Applicants must have the support of their employer to participate fully.
  • Participants in the Leaders for Geelong program are chosen on merit and their fit with the overall demographic balance of the group. Thesuccess of the program depends on the diversity of the group sobalance is achieved by ensuring there isrepresentation from local government areas, community sectors, professions, age and gender. Any applicant who is unsuccessful should not be deterred from applying again in the future.
  • The Committee for Geelong invites broad representation and inclusion in the Leaders for Geelong program. Individuals or organisations with financial or economic barriers should not be discouraged from applying. Contact the Program Development Manager to discuss the individual circumstances in confidence.
  • All applications will be subject to confidential evaluation and a shortlist of applicants will be interviewed by a panel. Applicants will be informed of the outcome by 30 June 2014.

Leaders for Geelong Program Application 2014page 1

How to submit your application

Submit your completed your electronic form to

Please also mail a signed hard copy to: Rosemary White, Leaders for Geelong Program, PO Box 1418GEELONG VIC 3220

Applications close COB 30 May 2014

Contact Rosemary White on 5227 8293 if you have questions regarding the application process.

Leaders for Geelong Program Application 2014page 1

PERSONAL DETAILS

Surname:
First Name: / Preferred Name:
(Name tags etc.)
Date of Birth: / Male: / Female:
Organisation/Employer:
Current Job Title:
Date of commencement in this role:
Business Address:
P/Code:
Telephone: / Bus: / Mob:
Business email:
Home Address:
P/Code
Home Telephone:
Home email:

EMERGENCY CONTACT DETAILS

Name of emergency contact
Business hours contact number
mobile contact number

EMPLOYMENT / EXPERIENCE:

Please provide a brief description of your current role, responsibilities, staff, etc.
does your work require you to be out of the region? If so, Approximately how many days per month? / Days
Previous employment in chronological order
Employer / Title / Responsibility / DATES
From / To
What do you consider your proudest career achievement to date?

EDUCATION:

Institution / City / Years / Qualifications &Major Studies
From / To
Note any extra-curricular activities / leadership activities during education
List any leadership training courses / subjects you have completed via study, employment or voluntary work
Will you be enrolled for any formal qualifications for the next year? If so please specify

COMMUNITY ACTIVITIES AND ORGANISATIONS:

What are your main community interests?
Please list in order of importance, up to five community, civic, professional, business, religious, social, sports and other organisations of which you are, or have been a member, and any positions of responsibilityheld in those organisations.
Organisation / Approx. date of Membership / Level of involvement and time commitment
What kinds of volunteer activities would you like to pursue in the future?

COMMUNITY AWARENESS:

What are the two most exciting opportunities available to the Geelong Region?
1
2
What do you believe are the two most significant issues / challenges facing the Geelong region today?
1
2
What do you feel needs to be done on one of theseissues?

PERSONAL:

What are your reasons for nominating for the Leaders for Geelong program and what do you hope to gain?
What particular strengths and experiences will you bring to the Leaders for Geelong program?
How do you expect youremployer/ organisationwill benefit from your successful completion of the program?
How do you expect your local community or region to benefit from your successful completionof the program?
Who is your personal inspirational leader or role model and why?
please describe yourself in a few phrases
How did you first hear about the Leaders for Geelongprogram?
CEO/Employer / Newspaper / Radio / Advertising
Other (please specify)

PARTICIPANTCOMMITMENT:

TIME COMMITMENT

The Leaders for Geelong program is a two year commitment commencing in July 2014 and concluding in June 2016. Essential elements include:

  • One to two core program events each month including one full day program (from 9.30am to 5.00pm) and an evening event (from approximately 4.00pm to 8.00pm)
  • Compulsory two day(Fri/Sat) residential program at both the start and the end of the program
  • Attendance at the two day Canberra program
  • Optional events and activities offered throughout the program. (Attendance is encouraged but not required.)
  • An active learning project undertaken with your fellow participants.

Participants are required to maintain a minimum attendance of 80% across all core program events. Inability tomeet the 80% attendance requirement may result in consultation with the participant’s employer and / or possible dischargefrom the program.

FEES

The fee for the two year Leaders for Geelong program is $6,000 plus GST. This fee may be paid by the participant or the employer. The total feeis payable on acceptance into the program.

Individuals or organisations with financial or economic barriers should not be discouraged from applying. Contact the Program Development Manager to discuss the individual circumstances in confidence.

……………………………………………………………………………………………………………………………..

EMPLOYER or SPONSORAGREEMENT

This candidate has my full support to participate in the two-year Leaders for Geelong program. I am aware of the time commitment, organisational and financial contribution. Should this candidate be selected:

My organisation is willing to participate by hosting a program session during the program and supplying basic catering.

YesNo

My organisation is available to provide support in the way of guest speakers and information.

YesNo

Employer / ceo Name: / Job Title:
Signature: / Date:

APPLICANT AGREEMENT

I declare that the information supplied by me is true and correct. I understand the goals of the program and the time commitment required of a participant in the Leaders for Geelong program. If selected for the program:
I will devote the required time to attendance and personal involvement.
I understand that I am committing to increased activity in the community upon graduation.
Applicant’s Signature: / Date:

PHOTOGRAPH, VIDEO & AUDIO CONSENT, DISCLOSURE INFORMATION

If selected for the Program, I agree to be profiled/photographed by the Leaders for Geelong Program and/or Committee for Geelong and consent to the use of the profiles/photographs for use in Leaders for Geelong and Committee for Geelong advertising, marketing or promotional/commercial materials, teaching and learning research materials. This may involve use in web sites, publications, presentations, newspapers, advertisements, CD-ROMs, DVDs, banners/signage/posters and other digital or print formats. I understand that the copyright in the profile/image is owned by Leaders for Geelong and the Committee for Geelong.

Privacy Statement

Your name and contact details are collected on this form in order to have a record of your consent to the taking of and use of images/profiles and to be able to contact you about these if necessary. The Leaders for Geelong Program and the Committee for Geelong is subject to the Information Privacy Act 2009 (Vic). You have the right to gain access to your personal information held by the Leaders for Geelong Program. To do so, contact

Applicant’s Signature: / Date:

If selected for the Program, I give permission for my email address to be shared with other Committee for Geelong leadership program participants and alumni, and members of the Committee for Geelong for the purpose of sharing information throughout the duration of the program and beyond.

If selected for the Program, I agree to the disclosure of my personal information collected on this form, excluding any health or medical related information, to Australian Authorities and Institutions/Companies involved in the delivery of the program as is necessary to allow my participation in any or all activities during the program.

Disclosure Statement

The Committee for Geelong are committed to protecting and respecting the privacy of its members, staff and participants by handling all personal information securely and with care in accordance with Australian privacy laws. Your personal information is collected on this form in order to affect your participation in the Leaders for Geelong Program. You have the right to gain access to your personal information held by the Program and you may withdraw your consent to share your email address at any time. To do so, contact

Applicant’s Signature: / Date: