Houma Terrebonne Chamber

Apply for next class

Thank you for your interest in Leadership Terrebonne. Please fill out the application below and someone will contact you.

1. PERSONAL DATA

Please include your first, middle and last name.

Full name

DATE

Preferred Name for Nametag

Age

Gender:

Female
Male

The completion of the section on ethnic background and handicap accommodations is voluntary. The information is helpful to ensure the diversity of the class.

Ethnic Background

Home Address

Mailing Address

Business Phone

Fax Number

Email Address

If Married, Spouse's Name

Spouse`s Name

Spouse`s Occupation

Number of Children

Names and Ages of Children

Hobbies

2. EMPLOYMENT

Present Employer

Starting Date

A. Please indicate the one category which best describes the area in which you presently work or serve.

Service area

B. Briefly describe your responsibilities in your employment.

Briefly describe

Business/Professional Affiliations (if any): (Do not include civic organizations, public or political activities.)

Name of Group

Positions Held or Assignments

Period of Service

3. COMMUNITY INVOLVEMENT

A. List in order of importance to you (up to three) community, civic, religious, political,

government, social, athletic, or other activities in which you are/ have been a member.

Do not include business/professional activities. Indicate major role in the organization at

this time.

1. Organization

Assignment/position

Describe responsibilities or leadership positions held

2. Organization

Assignment/position

Describe responsibilities or leadership positions held

3. Organization

Assignment/position

Describe responsibilities or leadership positions

4. EDUCATION

(Begin with high school, colleges, advanced degrees and/or specialized training)

A. Name and Location of School/Dates-Degrees/Certificate area of interest

A. What specific skills or knowledge do you hope to gain from your participation in Leadership Terrebonne?

General Information

B. What specific skills or knowledge do you hope to bring to the Leadership Terrebonne class?

General Information

REFERENCES

Name

Business Address

Name

Business Address

Name

Business Address

TUITION

Tuition is $850.00 per participant. If payment in full is made by December 31st, tuition will be $800.00.

Will you pay the tuition fee?:

YES
NO

Will your employer/sponsor pay the tuition fee?:

YES
NO

A limited number of partial schlorships are available to those participants needing assistance.

Signature of person responsible for payment of tuition?

When applying for a scholarship, a letter explaining the need for a scholarship must accompany the application.

Do you need to apply for a scholarship?:

YES
NO

COMMITMENT

If selected as a participant in Leadership Terrebonne, I am willing to attend all of the functions sponsored by the program that includes an overnight retreat, and one full weekday each month.

The overnight retreat is mandatory. I understand that should I miss more than two sessions for whatever reason, I will be dropped from the program and no portion of the tuition will be refunded.

I hereby certify that the information in this application is complete and correct. I understand the above commitment and agree to be bound by it in signing this application.

Commitment

Applicant`s signature

Date

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