LEC Application

First and Last Name

Preferred First Name

Home Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Phone *

Email Address

Length of time living / working in the area? *

Gender *MaleFemalePrefer not to answer

T-shirt Size:

Current Employer

Business Address

Apartment, suite, etc

City

State

ZIP / Postal Code

Country

Work Phone *

Work Email Address

Current job title and responsibilities: *

How did you become aware of LEC?

NewspaperRadioEmployerWord of Mouth

Community Involvement / Accomplishments: Please list any and all community, civic, professional, business, religious, social, athletic, and / or other such efforts in which you have participated in recent years. Please describe your involvement, responsibilities, offices held, awards or special recognition. Feel free to include any notable accomplishments.

Additional Information

Please list your personal and professional short term and long term goals and how you expect the Leadership Elk & Cameron program to assist you in meeting those goals.

Please provide a list of no more than three (3) significant challenges that you see facing your community and Elk and Cameron Counties in the near future. Feel free to “briefly” explain your list of challenges.

Benefits for sponsors and employers

The LEC program cultivates a more informed and responsible employee who can use new skills, knowledge and contacts for the benefit of their organization and community support organizations.

Financial Commitment

Program Tuition is $755 per participant. The application deadline is July 14, 2023. Save $100! Early bird tuition rate is $655 if application is submitted on or before June 16, 2023. Cameron County residents are eligible for special scholarships from the Emporium Foundation. An invoice will be sent and full tuition is due within 14 days of acceptance into Leadership Elk & Cameron Counties. The candidate is encouraged to seek sponsorship funding from his/her employer.

Financial Assistance: A limited number of tuition subsidies (partial scholarships) may be available to candidates based on financial need. Please select Yes or No to be considered for Financial Assistance *

YESNO

Acceptance

Final acceptance is contingent upon this application and an informational interview. Interviews will be taking place in early August, and notification of acceptance will be made by the end of August.

Personal Commitment

Leadership Elk & Cameron requires a total commitment from all participants enrolled in this valuable course. In order to achieve all objectives, successful candidates are required to attend all scheduled sessions. The program is scheduled to run from early September – mid-June.

I understand and accept the goals and purpose of the Leadership Elk & Cameron program, and if selected, I will attend all scheduled sessions / functions related to the class and complete all assignments. I will only be allowed two excused absences and a third absence will mean my removal from the program without tuition reimbursement. I understand that if I fail to meet these obligations, I may be asked to withdraw from the program.

Upon graduation, I pledge to assume a more active and effective volunteer role by committing at least one year of service to an Elk & Cameron community organization or group.

First Name *

Middle Initial

Last Name *

Employer Commitment

I will be the company mentor for the following company for the upcoming Leadership Elk & Cameron program year. I commit to following up with our employee on a regular basis to keep up on their progress and feedback.

Mentor Name

Title

Phone

Email Address

The students will be asked to follow the program requirements listed below:

I understand and accept the goals and purpose of the Leadership Elk Cameron program, and if selected, I will attend all scheduled sessions / functions related to the class and complete all assignments. I will only be allowed two excused absences and a third absence will mean my removal from the program without tuition reimbursement. I understand that if I fail to meet these obligations, I may be asked to withdraw from the program.

Leadership Elk & Cameron County Program Application Form

“Community leaders of today preparing the community leaders of tomorrow.”