2024 Leadership Robins Region Application

2024 Leadership Robins Region Application
GENERAL INSTRUCTIONS

Please complete each section, limiting answers as specified. Application deadline is December 1, 2023, or when we reach class capacity of twenty-five (25), whichever comes first. Participants are selected on a first-come, first-serve basis once the application process has opened. A delay in submitting a completed application may result in being placed on the waitlist for the 2024 program.
CONTACT INFO

Please enter your full legal name in the next three lines (some of our tour locations require security pre-screening).
First Name*
Middle Name
Last Name*
Preferred First Name (For Name Badge)*
Full Name Exactly as It Should Appear on Graduation Materials*
Work Phone Number*
Please enter a valid phone number.
Cell Phone Number*
Please enter a valid phone number.
Preferred Email Address*
example@example.com
Alternate/Secondary Email Address*
example@example.com
Business/Organization Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long have you lived in the Robins Region?

EMPLOYMENT INFO
Current Employer (Organization)*
Applicant's Current Job Title*
Briefly describe your responsibilities in your current job*
Current Supervisor's Title*
Current Supervisor's Name*

EDUCATION INFO
High School or GED (Name of Educational Institution) *
Post Secondary Education (Name of Educational Institution -College, Technical College, etc.)
Advanced Degrees (List Degree and Educational Institution)
List Special Recognition/Certificates/Achievements

ESSAY QUESTIONS
Please list, in order of importance to you, up to five civic, community, professional, social, or other organizational involvement, public offices held, and/or political activities.*
Please list civic/community organizations or causes you would like to become involved with in the future.*
What do you consider your most significant professional achievement or civic contribution?*
What are the three most pressing issues facing the Robins Region today, and why?*
What do you hope to gain from your participation in the Leadership Robins Region Program?*

STATEMENT OF ATTENDANCE & COMMITMENT

To graduate, attendance at all classes is expected. Classes typically begin at 8:00 am and conclude at 4:30 pm. Roll is taken at the beginning and end of each morning and afternoon session; each of which counts as ½ day (.5 day). Class members must participate in the orientation class and the retreat. If an absence is necessary, a total 1.5 absences of the remaining 9 training-day sessions will be excused. A late arrival or early departure of 30 minutes or more will constitute a ½ day absence. If a participant has a total of more than three ½ day absences, the participant will be dropped from the class. No Exceptions. Illness, bereavement, military orders, employer requirements, etc. do not excuse any additional absences.
YesNo
YesNo
YesNo
YesNo
Printed Name*
Date*
Signature*

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PHOTOGRAPH AND MEDIA RELEASE

I understand that photographs and video may be taken of the participants during the course of the Leadership Robins Region program. I consent to such photographing and videotaping for the use by Leadership Robins Region and the Chamber, without compensation, of my name, image, likeness, whether in film, photographs or any other media for the promotion by the Chamber of Leadership Robins Region and other activities of the Chamber.
I have read, understand and agree to the statement above.
Printed Name*
Date*
Signature*

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GENERAL RELEASE FORM

In consideration of agreeing to participate in the Leadership Robins Region program, the Participant hereby releases the (i) Robins Regional Chamber (the "Chamber"), its agents, officers, servants and employees and (ii) any third parties providing facilities or work space access to the Participant while engaged in the Leadership Robins Region program, from any and all liability, claims, demands, actions and causes of action whatsoever arising out of or relating to any loss, damage or injury that may be sustained by the Participant or any property of the Participant while engaged in or under the control or supervision of the Chamber during the course of the Leadership Robins Region program. The Participant is duly aware of the risk and hazards inherent in participating in physical activities associated with trust and team building activities of Leadership Robins Region and is also aware of the potential risk and dangers inherent in workplaces and other locations the Participant may visit during the course of the Leadership Robins Region program. The Participant hereby voluntarily assumes all risk of loss, damage or injury that may be sustained by him or her or any property belonging to or in the possession of the Participant while engaged in the Leadership Robins Region program. Furthermore, to the extent that negligent or reckless actions of the Participant may cause damage to the workplace or facilities of third parties assisting with the Leadership Robins Region program, Participant agrees to indemnify and hold harmless Robins Regional Chamber from liability for such damage or injuries to third practices attributable to the negligent, reckless and/or intentional acts of the Participant.
I have read, understand and agree to the statement above.
Printed Name*
Date*
Signature*

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