Adult Application

Leadership UA Adult Application, 2008-2009 Class

Name______________________________________________________________

Mailing address_______________________________________________________

_____________________________________________ZIP________________

Email______________________________________________

Home phone_________________________________________

Employer___________________________________________________

Position_____________________________

How long have you lived or worked in Upper Arlington?

Lived?_________________

Worked?_______________

Daytime phone____________________________ cell___________________

Briefly describe your present work responsibilities:

Education, degrees and specialized training (if you have a resume, please attach a copy to your application):

Community involvement (if necessary attach 2nd sheet):

What do you hope to gain from this program?

References: Please provide the names and contact information for two people that we may contact about your leadership potential, performance, and qualifications as a participant.

Tuition for the program is $750 and covers all program costs including the overnight weekend retreat and dinner at each class. Tuition is payable in full by the first class session unless otherwise arranged.

Is your employer paying your tuition? ________

Are payments necessary? ________

A limited number of scholarships may be available, do you require financial assistance? ______       If so, how much? _________

All classes are on Thursdays from 5:00 until 9:00 PM except for the overnight retreat.
    September 25
    October 9 and October 23
    Overnight Retreat, Camp Akita from:
          Friday Oct. 17, Noon - Saturday, Oct. 18th at Noon
    November 6 and November 20
    December 4
    January 8 and January 22

February 5 and February 19

March 5

April 2, April 16, and April 30

The Leadership Program requires a time commitment. If you are unable to commit to the schedule, it is not in your best interest to apply at this time. Have you confirmed your availability for the scheduled dates?    Yes_______     No______

Do you have the full support of your employer for the time required to participate in Leadership UA activities?     _________________

To graduate with the class, participants are expected to:

•    Attend the weekend retreat
•    Attend and actively participate in all class sessions
•    Attend one City Council and one Board of Education Meeting (not indicated in above dates)
•    Participate in a group service project that will require additional time outside class

I understand the purpose of the Upper Arlington Leadership Program and the importance of my participation in all sessions. I agree to devote the time and resources necessary to complete the program. Additionally, I understand that if I miss more than one session, I may be unable to graduate with the class and that no portion of my tuition will be refunded.

Signature_________________________________________Date__________________

Please return your signed application by September 1st with a $50 deposit to:
    Mary Ellen Hatch, Executive Director
    PO Box 21190
    Upper Arlington OH 43221

Space in the class is limited. If your application is not accepted your deposit will be returned.