Leaders for Geelong Program

Leaders for Geelong Program Application 2013 page 7

LEADERS FOR GEELONG PROGRAM

CONFIDENTIAL APPLICATION

Please complete your application on this form. Completed forms must be signed and a scanned version emailed to Please also mail a hard copy to:

Rosemary White

Program Facilitation and Development Manager

Leaders for Geelong Program

PO Box 3092

GEELONG VIC 3220

Applications close COB Friday 19th April 2013

If you have any queries or difficulties in completing this form please call Jean or Rosemary on 5227 8073.

Surname:
First Name: / Preferred Name:
(Name tags etc.)
Date of Birth: / Male: / Female:
Organisation/Employer:
Present 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:

Leaders for Geelong Program Application 2013 page 7

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:

(Begin with most recent education or training)

Institution / City / Years / Qualifications & Major Studies
From / To
1. 
2. 
3. 
4. 
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 responsibility held in those organisations.
Organisation / Approx. date of Membership / Level of involvement and time commitment
1. 
2. 
3. 
4. 
5. 
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 these issues?

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 your employer/ organisation will benefit from your successful completion of the program?
How do you expect your local community or region to benefit from your successful completion of 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 Geelong program?
CEO/Employer / Newspaper / Radio / Advertising
Other (please specify)

PARTICIPANT COMMITMENT:

TIME COMMITMENT

The Leaders for Geelong program is a two year commitment commencing in July 2013 and concluding in June 2015. Essential elements include;

·  One to two core program events each month starting at 1pm and finishing at approximately 7.00pm

·  A compulsory two day (Fri/Sat) residential program at both the start and the end of the program

·  1 full day program conducted mid way through each year

·  A group project undertaken with your fellow participants in the middle phase of the program which requires a further 30 – 40 hour time commitment

·  Optional events and activities offered throughout the program. Attendance is encouraged but not required.

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

FEES

The fee for the two year Leaders for Geelong program is $5,000 plus GST. This fee may be paid by the participant or the employer. The total fee is payable on acceptance into the program. Special payment arrangements may be negotiated as required.

Two 50% scholarships are available to applicants from the Not for Profit sector.

Please indicate if you are a not-for-profit organisation Yes No

Do you wish to apply for a 50% Scholarship? Yes No

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

EMPLOYER or SPONSOR AGREEMENT

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.

Yes No

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

Yes No

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;

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 AND AUDIO CONSENT

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.

Applicant’s Signature: / Date:

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

DISCLOSURE INFORMATION

If selected for the Program;

I give permission for my email address to be shared with other program participants, Alumni of the Leaders for Geelong Program and the Barwon Community Leadership Program and members of the Committee for Geelong for the purpose of circulating information throughout the duration of the program and beyond.

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

Your personal information is collected on this form in order to effect 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:
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