* Required



It is the policy of Leadership Pioneer Valley to recruit widely, without bias and from a variety of communities. Our goal is to select a class reflecting the rich diversity of the Pioneer Valley. Please help us by completing the questions below regarding your age, geographic location, employment sector, race, and gender.

Current Employment

Previous Employment

Provide the three most recent


Indicate highest degree earned first

Special Recognition

Community Leadership

Describe up to four (4) present or past volunteer community involvement experiences (this can include volunteering in your child’s school or at church, sitting on municipal committee or non-profit board, or involvement in fundraising). Include any leadership positions you held, your responsibilities, and the dates of your involvement (beginning with most recent).

Short Essays

Respond to each of the following three questions. For questions one and two, please limit your response to 250 words (one-half page) per question. For question three, limit your response to 500 words (one page). We suggest that you write your essays in a separate document and copy and paste them into this form when you have completed them.


This form must be filled out completely, the terms agreed to by you and your *employer, and included with your application packet to warrant consideration.

Financial Commitment
uition is $3,200 which includes a suggested personal tuition of $300 paid by participant. Tuition assistance is available for those who are self-employed, employed by a small business, non-profit or public sector, unemployed or would otherwise be unable to participate for both employer and personal tuition. See Tuition. For information on financial assistance refer to the Tuition Assistance Request Form which must be submitted with this application if applying for assistance.

  • (must have completed scholarship request application)

  • Time Commitment

    Full participation by each member of Leadership Pioneer Valley is critical. Minimum requirements for graduation include:

    • Program Reception — September 24, 2013, 5:30 - 8:00 p.m. (required attendance — no exceptions)

    • Opening Overnight Retreat — September 27-28, 2013 (required attendance — no exceptions)

    • Monthly Seminars —Friday, Oct. 25, Nov. 22, Dec. 13, Jan. 10 , Feb. 7, March 14, April 11, and May 16. Commencement and group presentations on June 5 (2-6 pm). All monthly sessions run approx. 8:30 a.m. to 5:00 p.m. (sixteen hours of excused absence allowed)

    • Leadership Labs — To be scheduled by groups (full participation expected)

    It is vital that you and your *employer understand and honor these commitments. If you are unable to commit to this schedule, please do not apply at this time. Applications without your *employer’s signature will not be accepted.

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  • * Not applicable to self‐employed or those not employed.

60 Congress Street - Floor 2, Springfield, MA 01104-3419 | Phone: 413-737-3876 | Fax: 413-732-2593

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