Personal Data

Last Name:

* required

First Name:

* required

Home Address:

City:

State:

Zip:

Email:

* required

Phone:

* required

Years in the Greater McHenry County Area:

How did you learn about Leadership Greater McHenry County?

Event:
Presentation at:
Newspaper:
Friend or Colleague:
Other:

Personal Background

Completing this section is voluntary and confidential; however, the information will be helpful in ensuring the diversity of the class.

Age:

18-20
21-30
31-40
41-50
51+

Gender:

Female
Male

Community Service

Identify current community activities/involvement:

Education

List beginning with high school, college(s), advanced degrees and specialized training, where applicable.

Name of School Completed

Dates Attended

Employment

Employment is not a requirement for application. Please fill out if applicable.

Company/Organization:   

Address:

City:

State:

Zip:

Business Title/Position:  

Business Phone:  

Email Address:   

Which of the following categories best describes your current employer/occupation?

Business/Industry
Non-profit agency
Law/Media/Arts
Government
Healthcare
Education
Clergy
Other

Briefly describe your current job responsibilities:   

List previous positions held over the past five years starting with current employer and then other employment.

Employer

Title/Responsibility

Dates

Special Honors or Awards

List any special honors or awards (community, education or business) you have received and the year received:

Please answer the following question:

What do you consider to be the greatest need(s) of the Greater McHenry County Community? How do you think your leadership strengths and values contribute to improving the identified areas of need?

Time Commitment

The time commitment requires attendance at eight all-day sessions, held once a month on workdays, and participation in an opening two-day retreat, which will occur Friday and Saturday. Participants are also required to assist in planning programs. Occasionally, participants will be required to perform pre-class assignments, reading or research prior to program days to enhance the learning experience. Participants who fail to fulfill their attendance obligation will be asked to withdraw from the program.

Tuition

The tuition for the entire program is $2,000.  Full payment is due upon acceptance into the program.  A limited number of partial scholarships are available upon request; please complete the Tuition Assistance section giving all details.

Tuition Assistance

I would like to be considered for partial tuition assistance. Amount of tuition assistance requested: $ . Please indicate below your reasons for tuition assistance.

What is your organizations annual income?   Please indicate in your reason for request.

Signature - Please Check the Box Below to Sign

I understand the goals and commitments of the Leadership Greater McHenry County Program. If selected, I am willing to attend all the sessions/functions sponsored by Leadership Greater McHenry County and devote the time necessary to be a contributing member of the class. I understand that if I fail to meet thee obligations, I will be asked to withdraw from the program.

Leadership Greater McHenry County (LGMC)

NOTE, Step 2 instructions after clicking on Submit.