Leadership UA Adult Program Application

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

Contact Information:

Name_________________________________________________________

Mailing address_________________________________________________

_____________________________________________ZIP_____________

Email_________________________________________________________

Phone________________________________________________________

Employer______________________________________________________

Position_______________________________________________________

Background:

How long have you lived or worked in Upper Arlington:

Lived?_________________________________________________________

Worked?_______________________________________________________

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.

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.

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?___________________

Time Commitment: All classes are on Thursdays from 5:30 until 9:00 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 weekend retreat to explore leadership styles with the class members
• Attend and actively participate in all class sessions
• Attend one scheduled City Council Meeting (not indicated in above dates)
• 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 1st with a $50 deposit to:

Leadership UA
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.

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.