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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