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.

* 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