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Applicant Information

First Name *

Last Name *

Job Title *

Employer/Organization *

Business Address Line 1

Business Address - Line 2

City

Postal Code

Business Phone

Cell Phone

Email Address *

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Community Information

How long have you lived or worked in Keith County? *

Enter required value Less than 1 year 1-3 years 4-10 years 11-20 years More than 20 years Lifetime Resident

Please describe your volunteer, civic, church, nonprofit, or community involvement. *

How did you hear about the Leadership Program? *

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Leadership Interest

Why are you interested in participating in the Keith County Leadership Program? *

What do you hope to gain from the program? *

What leadership strengths would you bring to the class?

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Availability & Commitment

The Leadership Program meets one full day per month from August through May. Are you able to commit *

Yes

No

Do you anticipate any scheduling conflicts that may affect your participation?

Yes

No

Are you interested in participating in the Lincoln Government Days trip? *

(This determines the $325 vs. $125 tuition option.)

Yes

No

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Tuition

Tuition Option *

$325 Program Tuition (includes Lincoln Trip)

$125 Program Tuition (does not include Lincoln Trip)

Payment Preference *

Pay Online

Request Invoice

Employer Will Pay

Other

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Supervisor Approval

Supervisor Name

Supervisor Title

Supervisor Email

Has your employer approved your participation in this program? *

Yes

No

Self-Employed

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Agreement

Agreement *

I understand that participation in the Keith County Leadership Program requires attendance, active engagement, and participation in the class project and community service activities.

I understand that participation in the Keith County Leadership Program requires attendance, active engagement, and participation in the class project and community service activities.

I certify that the information provided is accurate. *

Electronic Signature (required)

Please type your full name.