Leadership Academy Application

PERSONAL INFORMATION

First Name*

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Last Name*

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Street Address*

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City*

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State*

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Zip Code*

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Employer

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Job Title

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Supervisor Name

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Supervisor Email

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Employer Street Address

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Employer City

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Employer State

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Employer Zip Code

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Home Phone

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Work Phone

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Cell Phone

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Personal Email Address*

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Work Email

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T-Shirt Size*

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Date of Birth (M/D/YYYY)*

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Marital Status*

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Race*

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LAMC does not discriminate on the basis of gender, religion, race or national origin.

Gender*

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LAMC does not discriminate on the basis of gender, religion, race or national origin.

Number of Years in Community*

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Name of Spouse

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Children, Names, Ages

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EDUCATION

Name of High School*

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Name of College/University

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Graduate Degrees

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CURRENT COMMUNITY INVOLVEMENT

Organization/Roles & Responsibilities

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Organization/Roles & Responsibilities

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Organization/Roles & Responsibilities

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Give examples of ways you have, or currently serve in Madison County?

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PERSONAL STATEMENT OF PURPOSE

How did you learn about LAMC?*

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Why are you interested in participation in the program?*

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What do you hope to gain from this experience?*

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REFERENCES & RECOMMENDATIONS
Please provide 2 references, one personal and one professional, from individuals who are knowledgeable about your professional performance, leadership potential and volunteer experience.

Reference 1 Name*

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Organization*

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Title*

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Phone*

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Email*

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Reference 2 Name*

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Organization*

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Title*

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Phone*

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Email*

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TUITION
Tuition is due by August 31, 2020.

Who Will Pay Tuition*

Employer

Self

Other-please explain how

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Explain Other

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I understand that tuition for the 2020-2021 year is $950 and must be paid by August 31, 2020.*

Yes

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I represent a non-profit organization and would like to be considered for tuition assistance.

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Please submit a statement of need for consideration.

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I have read the policies for LAMC and understand the expectations for participation in this program.*

Yes

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Medical/General Liability Release
I authorize the Leadership Academy of Madison County (LAMC) staff, volunteers, and representatives to obtain or provide medical care for myself, to transport me to a medical facility and to secure treatment (including but not limited to routine or emergency health care, hospitalization, injection, anesthesia or surgery) they consider necessary for my health. I agree to pay all costs associated with that care and transportation and agree to the release of any medical records necessary for treatment, referral, billing or insurance purposes. I fully understand that all participants are to abide by the rules surrounding the Leadership Academy of Madison County staff, volunteers, and representatives harmless from any liability or claims, which may arise out of or occur in connection with my participation in these activities. I authorize that all information on this form is accurate and complete, and I have not withheld any information.

*

I AgreeI Do Not Agree

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Photography Release

Leadership Academy of Madison County (LAMC) staff, volunteers, and representatives routinely document activities associated with the Academy through photography, videography, audio recordings and other forms of media. I recognize that this media will be used in LAMC presentations, reports, and promotional materials, including on the LAMC website and social media sites. I hereby waive my rights to privacy with respect to the use or release of the above-mentioned media. I further understand that no royalty fee or compensation of any character shall become payable to me by the Leadership Academy of Madison County by reason of such use. I hereby release Leadership Academy of Madison County and its staff, volunteers, and representatives from any liability in its use or the use by others. I agree that the Leadership Academy of Madison County may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content.

*

I AgreeI Do Not Agree

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I represent a small nonprofit, or a community member, and would like to be considered for tuition assistance (limited sponsorship dollars are available)

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Are you committed to attending at least 90% of the sessions?

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