2024 Leadership Form

2024 Leadership Form
Name

First NameMiddle NameLast Name
Preferred Name
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Number
Please enter a valid phone number.
Work Number
Please enter a valid phone number.
Email
example@example.com
Date of Birth

MonthDayYear
Date
Interests
Is your business sponsoring you?
Why do you want to take Leadership Southlake?
What are your expectations?
How do you think it will affect your business?
Education: major college, graduate school, business/trade school, and /or specialized training
Name and location of school
From

MonthDayYear
Date
To

MonthDayYear
Date
Degree
Major
Present Employer and Title
Type of Organization
Length of Employment
Responsibilities
Website
Business/Professional Affiliations (if any-not including civic organizations, public office, political activities):
Name of Organization
Position
Date(From-To)
Community Involvement
A. List community, civic, religious, political government, social or other activities in which you actively participate. Please do not duplicate anything already listed. List most recent first:
List:
B. What do you consider your most important accomplishment in one of these organizations?
Why?
How much time each month do you currently commit to volunteer work?
What kind of community activities would you like to become involved with in the future? Examples include city council, school board, chamber board, Rotary, etc.
Applicant Commitment Please read carefully. If selected, you agree to fulfill the following commitment:

I understand the purpose of Leadership Southlake and, if selected, will devote the time necessary to complete the program. I understand that the full-day ropes course, the trip to Austin and active participation in a community advocacy project are required elements in order to graduate.

I will attend the monthly class sessions from August 2024 to May 2025 and understand that missing the full-day ropes course, the trip to Austin and any more than two sessions will result in failure to graduate from the Leadership Southlake program. I also understand that I must actively participate in a community advocacy project to graduate.
Signature

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Date

MonthDayYear
Date
Please attach a recent photograph suitable for reproduction in the class directory

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For questions, please contact Tracy Matlock tracy@southlakechamber.com
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