Leadership Application

LEADERSHIP HOLLYWOOD CLASS XXXIV APPLICATION

Last Name

First Name

Home Address

City

State

Zip

Phone

Cell

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Place of Business

Business Title

Business Address

City

State

Zip

Phone

Fax

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E-Mail Address

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Emergency Contact information:

Name

Phone

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Is anyone in your family a graduate of Leadership Hollywood?
 Yes No

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

Who referred you to the Leadership Hollywood program

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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.

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Preferred Name for Name Badge:

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EMPLOYER AUTHORIZATION:

Employer's Name

Employer's Title

Name of Organization

Employer has approved the submission of this application and the time and financial commitment required to participate in this program.
 Yes, employer approves
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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 $595 for chamber members and $695 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
Date

CLICK HERE TO SUBMIT APPLICATION

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