Application Form || Leadership Pioneer Valley | Building Collaborative, Diverse Leadership for the Pioneer Valley

* Required

Name

First Name *

Last Name *

Personal

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.

Home Street Address *

Apt.

City *

State *

Zip *

Home Phone Number *

Cell Phone Number *

Email Address *

Age

under 25
26-35
36-50
over 50

Gender

Female
Male
Other gender indentity

Race

Hispanic/Latino
African American
Asian/Pacific Islander
Native American
Caucasian
Other:

Current Employment

Title *

Employer *

Employer Street Address *

Street 2

City *

State *

Zip *

Business Phone *

Business E-mail *

Report to * Title

Duties and responsibilities * Include any specific leadership positions, budgetary authority, supervisory responsibilities, numbers supervised (100 words max)

If self-employed, describe your work and your work environment (ex. Home office, etc.) 100 words max.

Previous Employment

Provide the three most recent

Title *

Employer *

Duties and responsibilities * 50 words max.

Dates employed *

Title

Employer

Duties and responsibilities 50 words max.

Dates employed

Title

Employer

Duties and responsibilities 50 words max.

Dates employed

Education

Indicate highest degree earned first

School *

City *

Dates enrolled *

Degree *

School

City

Dates enrolled

Degree

School

City

Dates enrolled

Degree

Special Recognition

List any special awards, accomplishments or recognition (100 words max.)

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).

250 words max. *

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.

How do you define civic/community involvement? What civic/community volunteer experience do you expect to be involved in five years from now? * (250 words max.)

What are you seeking from your Leadership Pioneer Valley experience? What unique qualities will you bring to a Leadership Pioneer Valley class? * (250 words max.)

Please describe a specific situation where you faced a significant challenge personally or professionally. How did you resolve or overcome the specific problem or obstacle? * (500 words max.)

COMMITMENTS FOR PARTICIPATION

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.

Employer Tuition Portion: $
Applicant Tuition Portion: $
Financial Assistance Requested: $

(must have completed scholarship request application)
Total Tuition: $ 3200

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.

By checking this box, I certify that I am the individual named below and have read and agree to the commitments for participation stated in this document.
Applicant Name
Date / MM / DD YYYY

* 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

Name

Personal

Current Employment

Previous Employment

Education

Special Recognition

Community Leadership

Short Essays

COMMITMENTS FOR PARTICIPATION

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