2023 Leadership Shelby Application

Application - Leadership Shelby Class of 2024

If you are interested in applying for the Class of 2024, please feel free to fill out the form below. The calendar portion of this application is located in the application form below as a PDF.

The signed calendar is necessary to be considered for the Class of 2024.

The Class of 2024 will start in August 2023.

This program is for Shelby County, Kentucky.
Applicant Details:
Mr/Mrs/Miss/Ms/Other*
Full Name*

First NameMiddle NameLast Name
Gender*

malefemale
Birth Date*

MonthDayYear
E-mail*
Mobile Number*
Telephone Number*
Present Address*

Street Address

Street Address Line 2

CityState

Zip Code
Permanent Address*

Street Address

Street Address Line 2

CityState

Zip Code
Years residing/working in Shelby County
Expected Tenure in Shelby County
How did you hear about Leadership Shelby?
T-Shirt Size*
Person to contact in case of emergency:*
Relationship*
ex. Father, Mother, etc.
Phone number of person to contact in case of emergency*
Fees Information:

Please provide information as to who will be paying your program fees.
Who is expected to pay your fees?*

YourselfSponsor
Name and address of who is paying your program fees (if different from above).
Education:

List High School, College, Business, or Trade Schools and Specialized Training

	Name of secondary School/College/University	Address	Dates Attended From(mm/yy)To(mm/yy)	Degree/Major

Employment:

Please give details of curent and previous employers, together with dates.

	Organization	Position held and summary of responsibilities	Date From(mm/yy)TO (mm/yy)	Employer's Address

Have you taken any of the following strengths/personality assessments?

DISCMyers BriggsStrength Finder
Community Involvement:

Please list, in order of importance to you, up to four community, civic, religious, or social organizations of which you are or have been an active member.

	Organization	Your Role/Position	Date From(mm/yy)TO (mm/yy)

Hours committed each month to community involvement?
Awards for community involvement?
What do you consider your most important community service endeavor to date? Why?
Written Interview Questions
In 75 words or less, please explain your goals if selected to participate in Leadership Shelby.*
In 100 words or less, identify a major challenge or opportunity facing Shelbyville/Shelby County in the next five years. How would you, as a community leader, address this issue? *
Letters of Recommendation

Please Upload TWO letters of Recommendation below:
Letter of Recommendation # 1

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Letter of Recommendation # 2

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Scholarship Assistance
Please enter in the box below, in 200 words or less the reason for your request and the amount requested. No more than $500 may be awarded.
COMMITMENT

To graduate from Leadership Shelby, participants are expected to attend each monthly session for the full day. (Two excused absences may be permitted.) Our opening retreat is overnight and the closing retreat is a one day out of town meeting. Attendance of both retreats is mandatory. There are no exceptions. Applicants selected for Leadership Shelby will be billed for the $550 non-refundable tuition payable no later than July 31st. If selected I will devote the time and resources required to fully participate in the program.

I understand if I am absent from more than two sessions, I will be required to withdraw from the program and my tuition will not be refunded. The signatures below indicate mine and my employer’s commitment to the application, attendance and tuition requirements. Late or incomplete applications will not be considered. Applicants will be notified by email of their acceptance by June 15th. It is your responsibility to remit the $550 tuition which must be received by Leadership Shelby no later than the July 31st deadline. If you are a scholarship recipient and do not complete the program you will be required to reimburse the Leadership Shelby scholarship fund.

In addition to your signature below, please attach below the Leadership Shelby Program calendar signed by you and your employer.
Upload Leadership Shelby Program Calendar with your signature and your employer's signature.*

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Declaration

I certify that, to the best of my belief, the information I have provided is complete and true.
Signature

Clear
Date

daymonthyear
Payment of Application Fee

prevnext( X )
USD
I prefer to pay:

OnlineBy Check
Checks for the $20 Application Fee can be made out and mailed to Leadership Shelby:

Make check payable to:

Leadership Shelby

Mail to:

P.O. Box 24

Shelbyville, KY 40066

Should be Empty:

First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Applicant Details:

Fees Information:

Education:

Employment:

Community Involvement:

Written Interview Questions

Letters of Recommendation

Scholarship Assistance