First Name *

Last Name *

Cell Phone *

Personal Email *

Home Address

Home City

Home State

Home Post Code

How long have you lived in the Lansing area?

Male or Female

Male Female N/A

Age

Under 25 25-35 36-50 50-Over

Organization *

Email *

Phone *

Address Line 1 *

City *

State *

Enter required value

Postal Code *

Employed Since

Title

Questionnaire *

Please upload a file containing answers to the below questions.

1. Biography

Please write a brief biography in paragraph form to be featured in the orientation booklet 

2. Leadership Impact

Tell us about an experience or situation in which you assumed a leadership role and the results of those actions 

3. Personal Insight                                                                                                                                                   

What is one major issue facing Lansing that you are concerned about and what recommendations do you have for addressing this issue?

4. Participation

What qualities would you bring to Leadership Lansing? 

5. Personal Statement

What do you hope to gain by participating in Leadership Lansing? 

6. Community Vision

What is your vision for the Lansing region?

20MB max

Community Connections *

Please list your involvement in professional organizations, business and community board service and volunteerism. (Include: Name of Group, Positions Held and Period of Service)

Name of Group *	Position Held *	Period of Service *
			Del

Add row

Tuition *

Tuition for the Leadership Lansing program is $2,200 per participant. Tuition is payable to the Lansing Regional Chamber of Commerce and is deductible under the Internal Revenue Service Code as a business expense. Companies with multiple applicants will receive a tuition discount of $200 per applicant.

Acknowledgment *

I have discussed with my employer my intention to participate in the Leadership Lansing program. I understand that attendance at ALL scheduled Leadership Lansing sessions is mandatory because my participation is essential to the program's success. I have received permission to be absent from work one full day a month. I have also discussed with my employer the importance of my participation in each session and that absence could result in my dismissal from the Leadership Lansing program. If for some reason I must withdraw from Leadership Lansing, notification must be given two weeks prior to the first class. If notification is given later than that, a $500 fee will be assessed.