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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Is your employer in support of your participation in LAMC and aware of the time commitment?

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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 Address

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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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Number of years working or living in Madison County*

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List any Alumni of LAMC, YLA or BALANCE that you know

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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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PAST AND CURRENT COMMUNITY INVOLVEMENT

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

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PERSONAL STATEMENT OF PURPOSE

In a sentence, how did you learn about LAMC?*

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In a paragraph, why are you interested in participating in the program?*

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In a paragraph, 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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Email*

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Reference 2 Name*

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Relationship to Applicant*

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Years Known*

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Email*

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TUITION

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 2022-2023 year is $950 and must be paid by August 31, 2022.*

Yes

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I represent a small non-profit, or a community member, and would like to be considered for tuition assitance (limited sponsorship dollars are available)

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Please submit a statement of need for consideration.

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I understand the expectations for participation:

1. Attendance is required for opening retreat.

2. No more than two session absences are allowedto be considered for graduation.

3. Tuition is not reimbursable after opening retreat.

I accept the expectations for participation

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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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LAMC Application

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