Leadership Program Application

Bridging Brown County Leadership Program Application

Tuition fees for 2019-2020 is $375 for nine leadership days.
This includes all meals, refreshments, training and transportation.
Applications are due by July 20, 2019. The first session will be held on Thursday, September 19, 2019.

* Indicates required field

Name *

First

Last

Home Address *

Line 1

Line 2

City

State

Zip Code

Country

Mobile Phone Number *

Work Phone Number *

Personal Email *

Work Email *

Years living/working in Brown County *

The answers to the questions in this section are optional.
One of the goals of the program is to have a diverse class with ethnic, gender and professional balance. All information is kept confidential.

Age *

Ethnic Background *

Gender *

Community Involvement

Please describe present or past involvement in community or county organizations, activities, and volunteer work:

Please include organization and position held/responsibilities. *

Occupation

Place of Employment *

Employer Address *

Line 1

Line 2

City

State

Zip Code

Country

My employer is willing to make available the necessary time for full participation in all scheduled sessions. *

Yes No

Other work experience/training *

Why do you want to participate and what do you hope to gain from participating in the Bridging Brown County Leadership Program? *

Is there anything else you would like to share about yourself that would aid in the selection process? *

Do you need scholarship assistance to participate? *

Yes No

I understand the purpose of the Bridging Brown County Leadership Program, the requirement to attend the scheduled sessions, and that the completion of this application does not guarantee my acceptance as a participant. If selected to participate, I will devote the time required.

Signature *

Date *

Submit