Program Application 2018-2019
APPLICANT INFORMATION
First Name *
Last Name *
Preferred Name *
Gender *
How long have you lived/worked in Johnston County? *
Home Street Address *
City *
State *
Zip *
Home Phone *
Cell Phone *
Personal Email *
EMERGENCY CONTACT
Emergency Contact Name *
Relationship to applicant *
Emergency Contact Phone *
EMPLOYMENT INFORMATION
Current Employer *
Employer Mailing Address *
Employer City *
Employer State *
Employer Zip *
Employer Phone *
Work Email *
Position *
How long in your current position? *
Supervisor's Name
Supervisor's Title
Supervisor's Phone
Supervisor's Email
Which of the following best describes your present vocation? *
ORGANIZATIONS AND ACTIVITIES
List previous and current volunteer organizations and activities (indicate dates of membership/service and position held)
EXPECTATIONS
What is your definition of Leadership? *
What do you hope to gain through your experience in Leadership Johnston? *
COMMITMENT
To participate in Leadership Johnston, a major time commitment from October through June is required.

* Classroom training and tours will require approximately eight (8) working days over a nine (9) month period.
* Mandatory two-day, one-night team building retreat (Oct. 12-13)
* Additional time outside of the regular meeting times may be necessary.

FULL PARTICIPATION IS EXPECTED. No more than two (2) sessions or 16 hours may be missed and no refunds will be provided. If absences exceed 16 hours, you will not graduate with your class or receive your certificate.

Please upload a letter of recommendation from your immediate supervisor or a business colleague (doc, pdf, jpg files only) *
Required
FINANCIAL RESPONSIBILITY
The tuition for Leadership Johnston is $695.00 per person. Tuition includes expenses for the retreat, meals, transportation, and materials for the entire program. I understand the purpose of Leadership Johnston and, if accepted, will pay full tuition ON or BEFORE September 1, 2018.
APPLICATION AGREEMENT
By submitting my application and all required documents, I agree to commit to the Leadership Johnston program and financial responsibility as described.

APPLICATION DEADLINE: July 31, 2018

Personal Bio (to be used on program website and marketing materials) *
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