Please review the new applicant information before completing this application.

NOTE: We recommend that you save your work in Microsoft Word and cut and paste any essay answers to this application to avoid the loss of any work.

SECTION I: Personal Information

Full Name (include MI): Nickname: Email:

Where do you prefer to receive snail mail?

Address (Home): Town: State: Zip: Phone (Home): Fax (Home):

SECTION II: Current Employment

Job Title: Current Employer: Length of time at Current Employer: Address (Work): Town: State: Zip: Phone (Work): Fax (Work): Briefly describe your job responsibilities:
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What do you consider to be your most significant contribution or achievement related to your work?
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SECTION III: Prior Employment

Please list past employers, titles and dates of employment:
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SECTION IV: Education

Please list your educational background.
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SECTION V: Civic Involvement

Please list any organizations you are involved in (civic, religious, political, professional, social and others) and tell us how and why you become involved with them. What have you learned from your involvement?
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SECTION VI: Short Essays

How were you informed of Leadership Upper Valley's Leadership Institute?
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Why do you want to participate in the Leadership Institute? What do you expect to gain from the Institute and what will you bring to it?
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What will be challenging about dedicating a substantial level of time, energy, and attention to this program? How do you intend to address these challenges?
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What do you think are the three most important issues impacting the Upper Valley and why?
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SECTION VII: References

Please list the names, addresses, e-mail and phone numbers of two (2) references you have asked to submit letters on your behalf (please make sure that one is from your present employer, if applicable). Choose individuals who are knowledgeable about your leadership potential and performance.
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No application will be considered complete until both reference letters are received. Please have these two letters of recommendation sent directly to: Leadership Upper Valley, Vital Communities, 195 North Main Street, White River Junction, VT 05001 or leadershipuv@vitalcommunities.org.

If you are selected, would you like to have financial aid forms mailed to you?

(NOTE: Checking this box does not affect the consideration of your application.)

 

In order for your application to be considered, these boxes MUST be checked:

Yes, I have read and I understand the participant responsibilities of all Leadership Institute participants. I am able to fully participate in the Leadership Upper Valley Leadership Institute according to its guidelines.

I understand that the cost of the program is $1,275. Tuition is due in full by August 31, 2012. Session. Tuition is non-transferable and non refundable.

If my application is approved and I elect to participate in the Institute, I hereby authorize Vital Communities and its agents and employees to use my photo image of me in any all photographic video, audio, digital or other media, and to use produce, and edit any such recording or image, including my voice and image in personally identifiable form, in such a manner as they or any of them shall see fit, for any purpose, in all media, throughout the world, an unlimited number if times in perpetuity, including distribution over the Internet and its World Wide Web, and including use in modified form and in combination with other images or recordings. I further authorize Vital Communities to transfer or license the rights granted under this Consent and Release to third parties for purposes consistent with the mission of Vital Communities


195 North Main Street, White River Junction, VT 05001 | (802) 291-9100 ext 102 | leadershipuv@vitalcommunities.org
© 2012 Leadership Upper Valley, an initiative of Vital Communities.