Welcome! Leadership Kokomo Application (August 2022 - May 2023) Question Title * 1. Applicant Information Name (First, Middle, Last) Nickname Home Address (full address including city, state, zip code) Cell Phone Personal email Birthday (XX/XX/XXXX) *NOTE: Only used for Ivy Tech to officially enroll students LinkedIn profile (if any) Employer Current professional title Years employed by current employer Professional address (full address including city, state, zip code) Professional phone Professional email Question Title * 2. Relevant Experience: Past Employment Experience, Volunteer Experience, and Education Experience Prior Professional Experience #1 (Employer, Position, Dates Employed) Prior Professional Experience #2 (Employer, Position, Dates Employed) Prior Professional Experience #3 (Employer, Position, Dates Employed) Volunteer Experience #1 (Name of organization, your role/position, dates you were involved) Volunteer Experience #2 (Name of organization, your role/position, dates you were involved) Volunteer Experience #3 (Name of organization, your role/position, dates you were involved) Education #1 (Degree or Certification, School or Organization, Dates attended) Education #2 (Degree or Certification, School or Organization, Dates attended) Education #3 (Degree or Certification, School or Organization, Dates attended) Question Title * 3. Please answer the following questions either individually or combined:1). What do you consider to be your most important community service accomplishment to date?2) What skills or assets would you bring as a participant to the next Leadership Kokomo cohort?3). What do you hope to gain from your participation in Leadership Kokomo and how would you plan to utilize this experience?4). What is your definition of leadership? Question Title * 4. Does your employer support your application to the Leadership Kokomo program and accepts the time requirements necessary to participate? Yes No Other (please specify) Question Title * 5. If selected to be a member of the next Leadership Kokomo class, tuition will be billed accordingly. Tuition fees: $600 for Greater Kokomo Chamber members and $650 for non-members. What tuition covers: All programs costs with approximately 100 professional development hours, printed material, online learning management system access, speakers, room and meals at overnight retreats, and other meals offered at specific times during the program.Note that an application to the program does not automatically enroll you into the program, nor does it generate an invoice. Once the participate is accepted, then an invoice will be created. Do you and/or your employer accept this responsibility and understand the tuition requirements for the program? Yes, my employer supports my application and will be financially sponsoring my participation Yes, I will be self-paying for Leadership Kokomo, but my employer fully supports my participation in the program No Other (please specify) Question Title * 6. Employer sponsoring this applicant and supervisor Name of supervisor at your sponsoring employer Phone number for supervisor Email address for supervisor Question Title * 7. If selected, I will devote the time and resources necessary to complete the program. 1) To successfully complete the Leadership Kokomo program, participants are expected to fully attend all LK sessions and be punctual. (Two excused absences are allowed) Sessions are generally half-day sessions every other Tuesday from 8 a.m. - 12 p.m. noon. There are additionally a few full day commitments including a full day opening orientation and full-day (potentially overnight) retreat in October. Even though emergencies do arise, I understand that if absent from any part of the opening orientation or overnight retreat and/or more than two sessions, I may be asked to withdraw from the program by the Leadership Kokomo Advisory Council and my tuition will not be refunded. 2). There will be some outside work in the form of nonprofit board service, continued professional development, and volunteer opportunities. 3). I will uphold a standard of professionalism as a participant in the Leadership Kokomo program. My signature (in typed form) below indicates my commitment to and understanding of my responsibility of participating in the Leadership Kokomo program. Question Title * 8. Anything additional you would like Leadership Kokomo to know? Done