Participant Application Form

Application for Admission

to the District 5000 Leadership Academy 2022-2023
Name

First Name Last Name
Email address
example@example.com
Rotary Club
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Job Title
Organization
Rotarian Since
Club President Year
example@example.com
List Club/District Positions
Why do you want to be a part of the District 5000 Leadership Academy (DLA)?
What is your leadership goal?
If selected for participation in the DLA, I agree to participate in all sessions to the best of my ability and to complete the assignments given me by the DLA instructors.
Signature

Clear
Complete the application by August 1, 2022. Email Wendy Chang at wnnchang@outlook.com for more information.
Should be Empty:

Application for Admission