Hamilton County Leadership Academy Application

Completion of this application is required. All information is confidential.

Click here for a printable version (PDF) of this form. Fax to (317) 770-1540 or mail to PO Box 1414 / Noblesville, IN 46061-1414.

Class size is limited. Participants are selected based on leadership potential and demonstrated community interest. Candidates who are not selected are encouraged to apply again for future classes.

Name:
Nickname:
Gender:	M F
Home Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
Home Email:
Date of Birth:	/ /
Years living/working in Hamliton County:
Current Employer:
Title:
Work Address:
City:
State:
Zip:
Work Phone:
Fax:
Work Email:
If selected to participate, the tuition bill should be sent to:

Personal References

Name:
Company:
Phone:
Email:

Name:
Company:
Phone:
Email:

Name:
Company:
Phone:
Email:

Community Leadership
(describe present or past volunteer community leadership positions you have held)

Organiziation:
Date Involved:
Position/Responsibility:

Organiziation:
Date Involved:
Position/Responsibility:

Organiziation:
Date Involved:
Position/Responsibility:

Other Work Experience

Employer:
City/State:
From - To:
Position/Responsibilities:

Employer:
City/State:
From - To:
Position/Responsibilities:

Employer:
City/State:
From - To:
Position/Responsibilities:

Education

School:
City/State:
From - To:
Degree:

School:
City/State:
From - To:
Degree:

School:
City/State:
From - To:
Degree:

Other Activities and Accomplishments (list any other accomplishments, honors, offices held, activities, etc.)

General

How did you hear about the Hamilton County Leadership Academy?
Why are you applying to our program?
What challenges in Hamilton County would you personally like to learn more about?
Give any ideas or recommendations you may have for approaching and resolving these issues.
How do you hope to utilize your experience if you are accepted into the program?

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from the image:

Application Agreement

I understand that successful completion of this program requires full attendance at the opening two-day retreat, closing retreat, and 7 of the 9 monthly sessions, plus completion of the required class and civic projects. I also understand that a tuition fee of $1,250 will be charged to accepted applicants. My submission warrants that all information contained in this application is true and correct. If my application is selected, I will conduct myself in a manner befitting a community leader. I will devote the time and tuition resources required to fully participate in the Hamilton County Leadership Academy.

In the event the applicant commits a felony, is guilty of gross negligence or is incompetent in the performance of his or her duties, engages in conduct which, in the sole opinion of the Hamilton County Leadership Academy Board of Directors, brings the applicant into public disrepute, contempt or ridicule, or reflects unfavorably on the Leadership Academy, the applicant will be subject to termination from the program by a majority vote of the Board of Directors without a refund of the application fee.

Clicking Submit recognizes that you agree to these terms and conditions