LEADERSHIP HOLLYWOOD CLASS XXXVIII APPLICATION

Applicant Information

Please enter personal information about the applicant for the Leadership Program.

Last Name: *

First Name: *

Home Address: *

City: *

State: *

Zip Code: *

Phone: *

Mobile Phone:

Email Address: *

Business Information

Please enter information about your business or the business sponsoring this applicant for the Leadership Program.

Place of Business: *

Business Title: *

Business Address: *

City: *

State: *

Zip Code: *

Business Phone: *

Business Fax:

Emergency Contact Information

Please indicate an individual to contact in case of emergency.

Name:

Phone:

Miscellaneous

Is anyone in your family a graduate of Leadership Hollywood?: *

Yes

If YES, please list name(s) and relationship to you:

Who referred you to the Leadership Hollywood program:

Preferred Name for Name Badge:: *

Community

Community Involvement:

Please list community activities in which you are currently involved. Indicate any major role that you have had in these organizations.

Community Issue:

Please provide a brief explanation of a key issue that you believe currently faces Hollywood and briefly offer a possible solution.

Employer Authorization

Employer has approved the submission of this application and the time and financial commitment required to participate in this program.

Employer Name:

Employer Title:

Name of Organization:

Yes, employer approves: *

Yes

Applicant Acceptance

UPON ACCEPTANCE TO THE PROGRAM
I will commit to the appropriate dates and if I am accepted to the program, will attend kick off orientation sessions as well as all other regular scheduled sessions and the graduation ceremony in order to complete the program. I understand that any absence must be approved in advance. I also understand that the program tuition $750 for chamber members and $895 for non-members is due prior to the kick off day and I am responsible for any portion of the tuition not paid by my employer. Program tuition is non-refundable.

Yes, I accept the above terms: *

Yes

Date:

Education and Work Experience

Please email a resume that lists your educational background and employment history along with a professional headshot in .jpg format to programs@hollywoodchamber.org

DEADLINE TO APPLY IS SEPTEMBER 6, 2013