Personal Information
Name
*
First Name
Last Name
Prefix
*
Please Select
Dr.
Mr.
Ms.
Mrs.
Informal/Preferred Name
Date of Birth
*
-
Month
-
Day
Year
Date
Home Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
County of Residence
*
Calvert County
Charles County
St. Mary's County
Other
How many years have you lived or worked in Calvert, Charles, or St. Mary's counties?
*
Job Title
*
Years at Current Organization
*
Total Years of Full-Time Employment
*
Polo Shirt Size
*
S
M
L
XL
2XL
3XL
Food Allergies
Current Organization
*
Contact Information
Personal Phone Number
*
-
Area Code
Phone Number
Personal E-mail Address
*
Business Phone Number
*
-
Area Code
Phone Number
Preferred Phone Number
*
-
Area Code
Phone Number
Business E-mail Address
*
example@example.com
Preferred E-mail Address
*
Home
Business
Business Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Primary Business County
*
Calvert County
Charles County
St. Mary's County
Other
Where do you prefer to receive your mail?
*
Home address
Business address
How did you hear about LEAP?
*
Social media
Website
LSM alumni referral
Other
Demographic Information
Gender
*
Male
Female
Other
Age
*
Race/Ethnicity
*
African-American/Black
Asian-American
Caucasian/White
Hispanic
Multi-Racial
Other
Previous years you have applied to LEAP, if any:
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Professional Affiliation
Please choose one category that best describes what your organization does.
*
Arts
Business/Industrial
Defense
Education
Government
Healthcare
Law
Media
Nonprofit
Technology
Other
Is your employer a nonprofit organization?
*
Yes
No
Please list your last three employers, starting with the most recent:
*
Describe your current company/organization:
*
Describe your responsibilities at work:
*
Please provide a brief professional biography (250 words or less):
*
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Higher Education
If you have completed any higher education, please list starting with the most recent:
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Special Awards/Honors
Do you have any awards you’d like to tell us about (ex. scholarships, certifications, etc.)? Please list starting with the most recent:
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Community Involvement
Please list any community involvement or volunteering in the past five years, starting with the most recent:
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Open Answer Questions
Why is the LSM Emerging Leaders Program a good fit for you at this time?
*
What leader do you most admire and why?
*
What unique perspective or experience can you contribute to the class?
*
What do you hope/expect to gain from this program?
*
What do you consider to be your most important personal and professional accomplishment, and why?
*
Please describe your leadership journey so far:
*
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File Uploads
Please upload a professional color photo of yourself (business attire preferred):
*
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Please upload your professional resume:
*
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Please upload your letter of recommendation:
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Please upload your Official Authorizing Statement:
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Statement of Commitment
Who will be paying for this course?
*
I will
Employer or Other
I am requesting an LSM Nonprofit Scholarship (We will email you the scholarship application due October 31.)
A $125 Application Fee is required and non-refundable. The fee is waived, by means of a corresponding tuition reduction, for employees of 501(c)3 nonprofits who are accepted into the program. Please confirm how you will be paying:
*
Online
Personal check payable to Leadership Southern Maryland, P.O. Box 524, Leonardtown, MD 20650
You are required to submit an Official Authorizing Statement from your employer indicating their support of your participation in the program. By checking this box, you confirm that you will request an official authorizing statement. This statement must be uploaded with this application or emailed to info@leadershipsomd.org by September 30.
*
Yes, I confirm
Self-employed - no authorizing statement required
I understand that I am required to attend each session and meet the attendance requirements as outlined in the application information, and that missing more than 8 hours could result in dismissal from the program. I commit to take the knowledge that I've gained through this experience and to use it to strengthen our community. I understand that LEAP graduates are invited to maintain membership in Leadership Southern Maryland and to participate in committees and programs.
*
Yes, I confirm
Please add any additional supporting information we should know about:
Applicant Signature
*
Confirm your signature by printing your name:
*
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