Leadership UA Adult Program Application

Please print this page or download the application in either the MS Word Doc or Adobe PDF format.

 Leadership UA Adult Application – 2017-18 Class

Contact Information:

Name_______________________________________________________________________
Mailing address_______________________________________________________________
_______________________________________________________ZIP__________________

Email(s)______________________________________________________________________

Phone(s)_____________________________________________________________________

Employer_____________________________________________________________________

Position_______________________________________________________________________

Briefly describe your present work responsibilities:  _______________________________________

____________________________________________________________________________

Background:

How long have you lived or worked in Upper Arlington?

 

Lived?_________________________ Worked?______________________________

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.

  1. Name:___________________________________  Phone:___________________________
  2. Name:___________________________________  Phone:___________________________

 Financial Responsibility:

Tuition for the program is $800 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.

Time Commitment: All classes are on Thursdays from 5:30 until 8:30 PM unless otherwise noted.                    

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?

Yes_____   No______
To graduate with the class, participants are expected to:

  • Attend the full day program kick off called “A Journey of Self Awareness and Influencing Others”
  • Attend and actively participate in all class sessions
  • Participate in a class project that will require additional time outside class

Candidate Agreement:

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 10, 2017 with a $50 deposit to:
Leadership UA

Mary Beth Cowardin, 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. All questions and concerns may be directed to Mary Beth Cowardin via info@leadershipua.org.

I understand and agree that participants in the Upper Arlington Leadership Program may be photographed or video taped during the program, an associated activity or event.

I hereby give permission for the use of my photo, video and/or film likeness, and name by LUA, activity and event holders, producers, sponsors, organizers and/or their assigns for any legitimate purpose.

I will hold the released parties harmless for such use.

 

Application in MS Word format:

Leadership-UA-Adult-Program-Application-2017-18

Application in Adobe PDF format:

Leadership-UA-Adult-Program-Application-2017-18