Adult Program Sign Up

Name
Prefix First Last
Is there a nickname or other preferred First Name that you would like used on printed materials (name tags, rosters etc.)?
Home Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Cell Phone
Primary Email
Secondary Email
Date of Birth*
Date Format: MM slash DD slash YYYY
Spouse/Partner
First Last
Dietary Restrictions

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Present Employer
Name of supervisor (First, Last)
Supervisor's email
Business Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Business Phone
Type of Business
Your Title
Responsibilities
Date began
Preferred Mailing Address*
- Home
- Business
Please upload your resume (if available)
Accepted file types: pdf, doc, docx.

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Describe your employment history over the past ten years in reverse chronological order (including active duty military). Employer, Title/Responsibility, From, and to)
Describe your educational background including institutions attended, fields of study. degrees attained, awards, honors, etc.
In order of importance to you, please list up to five organizations of which you are, or were a member. You may wish to include civic, professional, business, religious, social, athletic, or other organizations.
What unique perspective or experience can you contribute to this Leadership class (Max 100 words)*
Discuss one specific problem you have observed in Geauga County. Tell why it is important. the issues it raises and make at least one suggestion for its solution (Max 100 words)*
What do you hope to gain and how do you expect to utilize your LEADERSHIP GEAUGA COUNTY experience? (Max 100 words)*

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Leadership Geauga County has a limited amount of financial aid available to individuals who could not participate in the program without subsidy. These funds are raised through corporate gifts, grants, and the annual fundraiser.
Would you like to apply?
- Yes, I would
- No, thanks
Applicant's Name
Please explain why you are applying for a scholarship. Scholarship funds are limited so more detail helps the selection committee make their decisions.
Scholarship Amount Requested

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