LEADERSHIP BEDFORD COUNTY
APPLICATION
CLASS OF 2024 (Aug. 2023-June 2024)
Leadership Bedford County, a program sponsored by Bedford County Chamber Foundation, adheres to EEOC guidelines and will not discriminate against individuals based on race, color, religion, sex or nationality.
Name
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First Name
Last Name
Business or Organization
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Business Phone Number
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Please enter a valid phone number.
Business Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Current Position/Title
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Email
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example@example.com
Briefly summarize your current job responsibilities.
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Briefly share your education and training, including any seminars or trainings you've attended in the last 5 yrs related to management, leadership or community service.
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Cell Phone Number
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Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
Home Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Community Involvement - Please list in order of importance three organizations (i.e. community, civic, professional,religious, social, athletic, etc.) in which you are or have been a member during the past five years. Please also share info about your leadership positions and/or significant contributions.
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How much time each month do you commit to community, civic and other organizations and activities?
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How did you become aware of Leadership Bedford County?
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Why do you want to participate in Leadership Bedford County and/or what do you hope to gain from being part of the program?
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Commitment to attendance the 2-day retreat in September is absolutely mandatory; only one absence is permitted for monthly sessions from October through June. Persons who cannot adjust their schedules to accommodate these days should not apply. Class members are expected to attend each day session in its entirety 8am-4:30pm). Are you and your employer willing to make such a commitment?
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YES
NO
NOT SURE
Full tuition ($1,500) is due prior to the retreat unless other arrangements are made. If you are selected, tuition will be paid by:
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MY EMPLOYER
ME PERSONALLY
ORG. SPONSORING ME
Do you need to be considered for partial financial assistance (scholarship)?
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YES
NO
Do you prefer to be contacted:
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WORK
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Signature
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