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Online Membership Application

The application deadline is Wednesday, March 24, 2010.

  Demographics
First Name:     Middle Initial:
Last Name:  
Address:  
City:  
Zip Code:  
Home Phone:  
Business Phone:  
Email Address:  
Lived in Johnson County:   Years     Non-Resident, worked or been active in Johnson County:   Years
Township:  
  Diversity
Note: The following questions are optional.  We are interested in them because one of the goals of Leadership Johnson County is to have a class of diverse ethnic, gender, age, geographic, and work related backgrounds.
Gender:   Male   Female   Unspecified     Age:  
Ethnic Background:   Asian/Asian American/Pacific Islander   Black/African American   Latino/Hispanic   Multiracial  
Native American/Alaskan Native   White/Caucasian   Unspecified
  Community Involvement
Please describe present or past volunteer community positions and any recent corporate, non-profit, elected or appointed positions.
  Organization: Date: Position / Responsibilities:
 
 
 
  Current Employment
Employer:  
Mailing Address:  
Position:  
Start Date:  
Vocation:  
Immediate Supervisor:  
  Past Work Experience
  Employer/Location (City/State): Position: From/To:
 
 
 
  Education
  School: City/State: From/To: Degree:
 
 
  Other Activities and Accomplishments / Military Experience
  Previous Application
Due to the limited number of participants for each class, it is sometimes necessary for applicants to apply more than one time.
Have you previously applied to the program?   Yes    No
If yes, please indicate the year you applied:  
  Interview Questionairre
Please take the time to thoughtfully consider your answers to each of the following questions.  Thank You.
1. From your leadership experiences with work, volunteering, community groups, church, schools, etc., what leadership qualities would you bring to Leadership Johnson County?
2. What do you hope to gain from your Leadership Johnson County experience?
3. What do you feel are the two most pressing challenges and issues facing Johnson County today? Explain why and give any recommendations that you may have for approaching and resolving these problems.
4. What skills, attitudes, and abilities do you feel are important to have as a leader?
5. Tell of a time when you were involved in your community and what benefits were realized.
6. Project yourself five years in time. What is your vision for Johnson County and what is your role in it?
7. How did you learn about Leadership Johnson County?
 
  Participant and Sponsor / Employer Agreement
By submitting this form you acknowledge that you have read and understand the requirements for successful participation in the Leadership Johnson County program and agree to meet all the requirements as stated.  Immediate Supervisor's approval is required.
 
 
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