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2014-15 Leadership Rockingham Application

Please fill out the form below if you are interested in participating in the 2014-15 session of Leadership Rockingham.
Note: Applications are due by noon on Friday, July 25th, 2014.

Error - The deadline for submitting your application was 07/25/2014. We are no longer accepting applications.
* required field
Personal Information
First Name *
Middle Name *
Last Name *
Preferred Name *
Address *
City *
State *
Zip/Postal Code *
Phone *
Email *
Gender * Female
Male
Race*
Years in Rockingham County*
Date Of Birth*
Birth Place*
Spouse
Number of Children
 
Employement Information
Employer's Name*
Employer's Address*
Employer's City*
Employer's State*
Employer's Zip*
Employer's Phone*
Employer's Fax
Current Job Position*
Length of Time in Position*
 
Education Information
High School * High School Name

High School - Dates Attended

High School Degree

High School Area Of Study


College * College Name

College - Dates Attended

College Degree

Collge Area of Study


Graduate Graduate School Name

Graduate - Dates Attended

Graduate Degree

Gollge Area of Study


Other Other Education Name

Other Education - Dates Attended

Other Education Degree

Other Education Area of Study

Special Honors/Awards/Recognitions
*List all special honors and awards you have ever received.
Current & Past Community Involvement *
*Please include information for the past five years

*How much time each month do you typically commit to community, civic, professional and other organizations of a volunteer nature?

*If you have not previously had the time or interest to become actively involved, what conditions, if any, have changed that now enable you to seek greater involvement in your community?

Are you a registered and active voter? * Yes
No

If not, please explain why.


*What are your chief hobbies and recreational interests?
General Thoughts
*What have you accomplished in your community involvement that you think is important?
*What do you hope to gain from participating in the Leadership Rockingham program?
References
*Please list two (2) people who are knowledgeable about your leadership performance/potential.
Include their name, address, city, state, zip and relationship to you.
Tuition
Tuition for participants is $595 and this amount covers all expenses including meals, program materials and retreats. Applicants will be notified of their acceptance by August 14, 2014 and tuition is due on Friday, August 25, 2014. (Tuition is not required with this online application.)
*Who Will Pay the Tuition?
Program Requirements
Participation in the Leadership Rockingham program requires significant time and commitment. Required sessions and activities include:
  • Meet & Greet Event - September 4, 5-7 PM (details provided in acceptance letter)
  • Overnight opening retreat — September 21 at 3:00 PM through September 22 at 5:00pm
    Would you be willing to share a room for the overnight retreat stay?
    Yes     No
  • Monthly sessions — October through April  8:00 AM to 5:00 PM
  • Visits to area organization meetings - (outside of class time)
  • A group project - developed/executed by your work group outside of class time
  • Closing retreat/graduation - May 13, 2015  8:00 AM - 3:00 PM
Your successful completion of the program is contingent upon your full attendance and involvement in all of the above activities. Are you aware of any of the program dates when you will not be able to be present?
Yes     No

If you answered "Yes," please list the date and give reason for anticipated absence below.

By submitting this application I understand the goals of the Leadership Rockingham program and if I am selected as a participant, I will pay my tuition by August 29, 2014 and I will devote the time as described above to the program.