Application to Participate in Leadership Northwest Missouri Trains Leaders to Grow Our Communities!

Tuition is $500, which includes lodging on January 23rd, all session meals, a participant notebook, and Leadership Challenge materials. Tuition scholarships of 50% may be available. Contact Deb Powers, Heartland Foundation (816.271.7185) for more information on scholarships and sponsorships .

Completed applications must be delivered or postmarked by October 31st, 2007 to: 518 S. 6th Street, St. Joseph, MO 64501. The Selection Committee will then review applications and select class members. Full payment is due before January 4, 2008.

You may complete the form below and submit your application online. Or, you may download and view/print the complete 2008 application as a Word file or as a pdf file.

Leadership Northwest Missouri
Attn: Deb Powers
518 S. 6th Street
St. Joseph, MO 64501

A program of Healthy Communities.

Application for 2008 Leadership Northwest:

PERSONAL DATA
Name:
Gender:	Female Male
Preferred First Name:
Date of Birth:
Company/Organization:
Present Title or Responsibility:
Length of Time with Employer:
Work Mailing Address:
Work City:		Zip:
Work County:
Work Phone:
Home Mailing Address:
Home City:		Zip:
Home County:
Home Phone:
Preferred Mailing Address: This address will be used to mail all important materials and will be made available to all class participants.	Work Address Home Address
Preferred Email:
Please Indicate Any Special Dietary or Accommodation Needs:
Highest Level of Education Completed...
Name of School:
City/State:
Degree:
LEADERSHIP ACTIVITIES
Leadership exists in many forms in the community. Please list and describe three (3) leadership experiences, in order of importance to you and why you believe you played an important role.
COMMUNITY INVOLVEMENT
To aid in the selection process, check the categories which best describe the sector in which you presently work or serve. Check either Work or Service (includes service, boardsmanship or volunteerism).	Business Services (banking, accounting, finance, law, etc.) Work Service Commercial/Retail (architect, construction, real estate, developer, etc.) Work Service Communication Services (public relations, advertising, media, etc.) Work Service Education (education administration, teacher/professor, etc.) Work Service Government (state/county/city/township administration, police, fire, etc.) Work Service Healthcare/Life Sciences (healthcare administration, provider, researcher, insurance, etc.) Work Service Manufacturing Work Service Non-Profit (social services, business services, etc.) Work Service Small Business/Entrepreneur Work Service Community Advocate/Volunteer Work Service
COMMUNITY CONNECTIONS
Please list your involvement in professional organizations, business and community board service and volunteerism.
Name of Group/Affiliation:
Positions Held:
Period of Time:
Name of Group/Affiliation:
Positions Held:
Period of Time:
Name of Group/Affiliation:
Positions Held:
Period of Time:
Name of Group/Affiliation:
Positions Held:
Period of Time:
Name of Group/Affiliation:
Positions Held:
Period of Time:
GENERAL INFORMATION
What do you hope to gain from your participation in Leadership Northwest Missouri?

Identify one significant issue facing northwest Missouri today. Explain why you chose this issue.

COMMITMENT
Tuition is $500, which includes lodging on January 23rd, all session meals, a participant notebook, and Leadership Challenge materials. Tuition assistance of up to 50% may be available. Contact Deb Powers, Heartland Foundation (816.271.7185) for more information on scholarships and sponsorships.
Attendance at all sessions is required! You are expected to attend every session. However, you will be allowed to be absent from one session with prior approval and permission of the Executive Director. An absence is missing a whole session or any part thereof. If you miss more than the one approved absence; you will need to make up the applicable session(s) the following year in order to graduate. New attendance policy effective with Class of 2005.
If selected, I am willing to attend all sessions/functions sponsored by Leadership Northwest Missouri and devote the necessary time to be a contributing member of the Leadership Northwest Missouri class. I understand that if I fail to meet these obligations, I may be asked to withdraw from the program and will not graduate with my class. I have read and understand the attendance policy stated above.
Applicant Signature: Note: Typing in your name here is equal to a legal digital signature.
Date:
I agree to pay Leadership Northwest Missouri the tuition for the above applicant, if accepted. I understand tuition is due by January 4th, 2008. No refunds will be made after the due date!
Financial Sponsor Name:
Title:
Signature: Note: Typing in your name here is equal to a legal digital signature.
Date:
I agree to allow my employee to devote the time necessary to be an active member of Leadership Northwest Missouri, if accepted.
Name:
Title:
Signature:
Date:

If you prefer, you may mail your completed Word file application to: Leadership Northwest Missouri Attn: Deb Powers 518 S. 6th Street St. Joseph, MO 64501

For more information, contact:
Deb Powers, Executive Director, Leadership Northwest Missouri

Director of Healthy Communities
Heartland Foundation
518 S. 6th Street, St. Joseph, MO 64501
Phone: 816-271-7185
Toll-Free: 1-800-447-1083
Fax: 816-271-7269