Download Our
2010 Brochure Here

(396KB PDF)

Tuition is $650, which includes lodging on January 27th, all session meals, a participant notebook, and Leadership Challenge materials. Tuition assistance of 50% may be available. Contact Lisa Luke, LNW Program Coordinator, at 660-582-1050 for more information on scholarships and sponsorships.

Completed applications must be delivered or postmarked by October 31, 2009 to: Leadership NW MissouriSM, P.O. Box 92, Cameron, MO  64429. The Selection Committee will then review applications and select class members. Full payment is due before January 8, 2010.

You may complete the form below and submit your application online. Or, you may download and view/print the complete 2010 application as a Word file or as a pdf file.

Leadership Northwest MissouriSM
Attn: Lisa Luke
P O Box 92
Cameron, MO  64429

Application for 2010 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:
Please check which address you prefer we use to mail all materials. This address will be made available to all class participants as well.

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 MissouriSM?

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

COMMITMENT

Tuition is $650, which includes lodging on January 27th, all session meals, a participant notebook, and Leadership Challenge materials. Tuition assistance of 50% may be available. Contact Lisa Luke, LNW Program Coordinator, at (660) 582-1050 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 Program Coordinator. 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 MissouriSM and devote the necessary time to be a contributing member of the Leadership Northwest MissouriSM 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 MissouriSM the tuition for the above applicant, if accepted.
I understand tuition is due by January 8th, 2010.
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
SM, if accepted.

Name:

Title:

Signature:

Date:

If you prefer, you may print, complete, and mail your PDF file application to:
Leadership Northwest Missouri
SM
Attn: Lisa Luke
P O Box 92
Cameron, MO  64429

Or, save, complete, and email your Word file application.

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For more information, contact:
Lisa Luke, LNWMO Program Coordinator
660-582-1050

LNWMO Mailing Address: PO Box 92, Cameron, MO. 64429

LNW is a 501 (c) (3) organization.

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