Leadership Clinton County Application

Leadership Clinton County Form

This form collects basic information as well as education, employment, three references, skills assessments, interests, and a simple, short essay section on: 

1. Your most significant accomplishments in volunteer service to date
2. Two issues, opportunities and challenges facing Clinton County in the next decade
3. What you hope to gain from your participation in Leadership Clinton County
4. Your potential role in the community in five years

First Name *

Last Name *

Preferred Name

Date of Birth *

Phone *

list your preferred phone number for communications

Email *

list your preferred email address for communications

Address Line 1 *

Address Line 2

City *

Present Employer *

Address Line 1 *

Address Line 2

City *

Brief description of job responsibilities *

List Previous Employers (including military duty) *

Education Level *

High School

Associate Degree

Bachelors Degree

Masters

Doctoral

Not Applicable

References *

Please list three references who are familiar with you and your potential contributions to your community. Provide your references with this online form: https://forms.gle/PgYCBChZweniVD2j7

Scholarships *

A limited amount of scholarship funds are available to participants with need. Would your participation depend on a partial scholarship?

Yes

No

Personal Commitment *

Leadership Clinton County is intense. It will consist of fourteen sessions within the nine month program (please review session dates prior to applying). In addition, participants are expected to attend meetings of organizations that interest them and complete projects outside of class. If you are unable to make this commitment and do not have your employer’s support, it is not in your best interest to apply at this time.

I understand the purpose of Leadership Clinton County, and if selected, will devote the time and energy necessary to complete the program. I will then work to improve my community in a manner appropriate for my interests and skills

Type your name as an electronic signature commitment

Interview *

Following the review of all applications, each applicant will be contacted by a Leadership Clinton County Advisory Committee member to schedule a 30 minute one-on-one interview. What time are you best available: 

8am-1pm

1pm-6pm

any time of day

Employer Commitment *

Applicants to Leadership Clinton County should have their employer’s support.  Your employer should review the session dates ahead of time to be sure of your ability to participate. It should be noted that tuition will not be refunded if the applicant is no longer employed by its sponsor. The applicant will be able to remain in the program if he/she chooses. Tuition reimbursement shall be handled between the applicant and employer. Once the application is received, a form will be sent to your employer to sign off. 

Please list your employer's name

Email *

Employer email address

Community Involvement *

Please describe any volunteer activities in which you have participated during the past 5 years.  Describe the nature of your involvement, responsibilities, offices held and awards or special recognitions.

No community Involvement *

If you have not been involved in any civic activities, please explain the barriers and how they might be overcome

Please evaluate your skills in the following areas *

Communication

Communication *	Working Cooperatively *	Publicity and Media Relations *	Leadership *	Conflict Resolution and Problem solving *	Managing Meetings *	Group Decision Making *
0 5	0 5	0 5	0 5	0 5	0 5	0 5	Del

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Interest *

Economic Development

Youth

Publicity and Media Relations

Public speaking

Leadership

Managing Meetings

Group Decision Making

Team Development and Management

Public Policy

Problem Solving

Your Most significant accomplishment in volunteer service to date. *

Two issues, opportunities and challenges facing Clinton County in the next decade *

What you hope to gain from your participation in Leadership Clinton County *

Your potential role in the community in five years *