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Leadership Academy Application

The purpose of the Leadership Academy of Madison County if to develop servant leaders by exposing our participants to the best practices for community leadership. Through a format of lecture, open dialogue, on-site visitation and class interaction, a participant will be exposed to capacities of leadership such as visioning, collaboration, community building activities and being a good Board member. We will meet twice during the year with the Youth Leadership Academy and service projects are coordinated through the Academy. We encourage class participants to attend all sessions except in the case of an emergency or illness.

Tuition for the 2018 -2019 year is $950 and can be paid by a sponsoring organization or by the participant. Tuition must be received by Opening Retreat unless payment options have been made.

SELECTION CRITERIA

  • Participants will be chosen by the Selection Committee based on application materials submitted by the candidates. Candidates are recruited from a representative cross- section of the community.
  • Participants must live in or work in Madison County. 36 candidates will be selected to participate.
  • Participants must have permission from their employer to be released from work to attend sessions.
  • Participants are expected to attend Opening Retreat and Closing Retreat (mandatory).
  • Participants must have motivation, interest, and a commitment to being a servant leader.
  • Applicants should demonstrate a willingness to commit themselves to active volunteer involvement in the community.
  • Program candidates must demonstrate an ability to achieve personal goals and have time available to dedicate to community service as well as a personal commitment to Madison County.
  • Participants who fail to attend more than one session are at risk for not receiving their certificate of completion.

APPLICANT COMMITMENT

  • Applicants are expected to serve and strengthen the community upon completion of the program.
  • Although some employers may have an internal selection process, submitting an application does not guarantee a position in LAMC.
  • The Selection Committee may be unable to place all eligible candidates, even if these applicants have demonstrated excellent credentials. These applicants are encouraged to apply for future programs.
  • Assignments outside of class sessions may be required. If selected, participants will be expected to attend all session and complete program assignments.

Please complete the following 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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Gender*
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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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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, 2018.
Who Will Pay Tuition*

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Explain Other
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I understand that tuition for the 2018-2019 year is $950 and must be paid by August 31, 2017.*
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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.*
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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.
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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.
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