Leadership Redwood City, Belmont, Menlo Park, San Carlos Application

First Name

Last Name

Address

City

Zip Code

Home Phone

Email

Cell Phone

How many years have you lived/worked in Redwood City/Belmont/Menlo Park/San Carlos?

How did you learn about our program?

 My Employer



 Chamber website/email



 Referral



 Other



Employment

Currently employed?

 Yes No

Present Employer

Job Title

Type of Business

Industry

 Other


Business Address

City

Zip Code

Length of time with employer

Business Phone

Business Email

Briefly describe your role/responsibilities

Previous Employment

Employer

Title/Responsibility

Dates




 More employment

Employer

Title/Responsibility

Dates


 More employment

Employer

Title/Responsibility

Dates

Education & Training

Name of School

Degree/Certificate


 More education

Name of School

Degree/Certificate


 More education

Name of School

Degree/Certificate


Other Academic Highlights or Achievements

Organizations, Activities and Civic Engagement

Please list, in order of importance to you, three community, civic, professional, business, social, athletic or other organizations of which you have been a member. Please briefly describe the nature of your participation, responsibilities, and accomplishments.

Organization 1

Date of Membership

Describe Involvement


Organization 2

Date of Membership

Describe Involvement


Organization 3

Date of Membership

Describe Involvement


If you have not been involved in any civic, business, professional, and voluntary activities, please explain why?

What do you hope to gain as a result of your participation with Leadership, Redwood City/ Belmont/ Menlo Park/San Carlos?

What are your areas of particular interest for leadership involvement in your community? Please rank from 1 through 10; 1 being your top rated topic of interest.

Government

Education

Housing

Economics & Business

Transportation

Land Use

Public Safety

Fundraising

Health Care

Getting started in volunteerism

Other - Is there a topic related to our community, not listed above that you would like to learn more about?

What is it about you that qualifies you for Leadership, Redwood City / Belmont / Menlo Park / San Carlos?

Participation

To successfully complete the Leadership Redwood City/Belmont/Menlo Park/San Carlos program, the participant must not miss more than 2 classes to graduate from the program.

Participants must have the support and commitment of their employer if not self employed.

Tuition

Applications received by July 1st will receive an early submission tuition of $1,300.00. Tuition increases to $1500.00 for applications received after July 1st. Credit card payment is accepted. Checks should be made out to Redwood City-San Mateo County Chamber of Commerce.

Other tuition funding sources, such as employer or sponsoring organization, may be utilized to pay for the participant's tuition.

Please indicate how your tuition will be paid:

 Self Employer Other

Please details instructions where to mail invoice. Complete mailing address with email address of contact required


Refund Policy

Withdrawal from the program following confirmation to participate may result in forfeiture of tuition unless Leadership Redwood City/Belmont/Menlo Park/San Carlos is able to confirm a replacement participant prior to the first session.

I understand that completion of this application does not guarantee a candidate's acceptance into the program. I am aware of the attendance requirements and if selected to participate, I will devote the time required.