Applicant Information Make sure to complete each section in its entirety. Incomplete applications will not be considered.
■ Male Female Full Name: ___________________________________________________________ Gender:
Address: __________________________________ City: ___________ State: ______ Zip code: _____________ Daytime Phone #: ___________________________ Age: __________ T-Shirt Size: S M L XL XXL
Other Size:_______________
Email: ____________________________________________ Are you an individual member of the Denison Area Chamber of Commerce?
Yes No
In case of an emergency, last minute changes, or cancellations due to weather, or for necessity during a class session, we ask that you supply the following phone numbers as well; these numbers will not be for public use. Cell Phone #: ___________________________ Evening Phone #: ____________________________ What is your current community involvement (civic clubs, organizations, volunteer work)? Prior community engagement is not a requirement of the program, but a goal of your participation.
____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________
What specific skills/knowledge do you hope to gain from your participation in Leadership Denison?
____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________
What do you feel is the most significant challenge facing Denison?
____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________
How did you hear about Leadership Denison?
____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________
How do you plan to “give back” to the Denison community, as a Leadership Denison Alum? __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________
Enrollment Application Leadership Denison Class of 2019
Denison Leadership Institute
Page 1 of 3
Professional References
Make sure to complete each section in its entirety. Incomplete applications will not be considered.
Name: ______________________________ Relationship: ___________________Phone: _________________ Address: _____________________________________ City: ____________ State: ______ Zip code: _____________ Name: ______________________________ Relationship: ___________________Phone: _________________ Address: _____________________________________ City: ____________ State: ______ Zip code: _____________
Professional Resume/Headshot Is your professional resume included with your application? Yes No Is your headshot included with your application? Yes No
Applicant Participation Agreement ______ The Denison Leadership Institute is a learning experience and requires attendance at monthly meetings, Initial here which are full-day sessions, over a period of eight months. ______ I understand attendance at the Retreat/Ropes Course (opening session) is MANDATORY. Initial here
______ I understand no more than 2 sessions may be missed due to illness, injury, or emergency and if more Initial here than 2 absences occur I will be dropped from the course without a refund. ______ I understand the tuition of $500.00 for Chamber members ($750.00 for non-Chamber members) is Initial here payable prior to the Retreat/Ropes Course (unless prior arrangements have been made with Jennifer Bohannon, DLI Coordinator). I understand that tuition is non-refundable after I have been accepted into the program, agreed to attend, and the 2019 class has been announced publicly. I understand the legal consequences of signing this document, including: a) releasing the Denison Area Chamber of Commerce from all liability, b) waiving my right to sue the Denison Area Chamber of Commerce, c) I assume all risks of participating in this program, including travel to and from activities or any events incidental to this program. I understand the above commitments and agree to be bound by them in the signing of this application. _________________________________ Applicant’s Signature _____________________ Date
Enrollment Application Leadership Denison Class of 2019
Denison Leadership Institute
Page 2 of 3
Employer Information
Make sure to complete each section in its entirety. Incomplete applications will not be considered.
Employer: ______________________________________________ Title: ___________________________________ Address: ______________________________________ City: ____________ State: ______ Zip code: ____________ Primary Responsibilities: __________________________________________________________________________ ______________________________________________________________________________________________ Will your employer be sponsoring your enrollment and paying the tuition? Yes No Is your company/organization a member of the Denison Area Chamber of Commerce? Yes No Supervisor’s Name: _______________________________ Supervisor’s Title: ________________________________
Employer Sponsorship Agreement ______ I understand the time commitment required of my employee to participate in Leadership Denison, a Initial here program of the Denison Area Chamber of Commerce. ______ If my employee is selected to participate, I approve his/her absence to attend all of the sessions. I Initial here understand if my employee does not adhere to the attendance policy, he/she will not be credited with successfully completing the program. ______ My initials also indicates that I agree to make the tuition payment, in full, prior to the Orientation/Ropes Initial here Course, and I understand the tuition guidelines. My signature further indicates that the applicant has the approval of our organization and we fully support his/her participation in the program. ____________________________ Supervisor’s Name (Printed)
____________________________ Supervisor’s Title
____________________________ Supervisor’s Signature _____________________ Date
Leadership Denison Contact Jennifer Bohannon, Denison Leadership Institute Coordinator PO Box 325, Denison, TX 75021 903-465-1551 (office)
[email protected] 903-465-8443 (fax)
Enrollment Application Leadership Denison Class of 2019
Denison Leadership Institute
Page 3 of 3
