Adult Leadership Roane County Application

Adult Leadership Roane County

Class Application
Name*

First NameMiddle NameLast Name
Preferred Name on Badge*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number*
Please enter a valid phone number.
Work Phone Number*
Please enter a valid phone number.
Cell Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Emergency Contact *

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
Relationship to the Emergency Contact*
List any Diet Restrictions:*
List any Physical Limitations:*
List any other special needs or requests:*
EMPLOYMENT
Employer Name & Phone Number:*
Your Title:*
Company Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
COMMUNITY ACTIVITIES/HONORS/AWARDS
Please list community organizations/activities in which you have been involved during the past five years. Please list in order of their value to you:*
How did you learn about Leadership Roane County?*
What do you expect to gain from the Leadership Program?*
TIME REQUIREMENTS AND TUITION
A major time commitment is required to participate in the Leadership Roane County program. As a candidate, you need to understand that absenteeism would prevent you
from graduating with your class.

Full tuition is *$550. This cost covers all your Leadership Roane County Program expenses. (An invoice will be sent at a later time if you are chosen for the class)

I understand the purpose of the Leadership Roane County program and will devote the time required. I also certify that I am a U.S. Citizen.
Applicant's Signature*

Clear
The above signature also serves as approval to use my photo for promotion of Leadership Roane County.
Date*

MonthDayYear
Date
Program is limited to 20 participants.

For questions please contact Kristi Beason at beasonk@roanestate.edu.

*Subject to Change
(Information on this application will be treated as confidential)
Should be Empty:

Adult Leadership Roane County

EMPLOYMENT

COMMUNITY ACTIVITIES/HONORS/AWARDS

TIME REQUIREMENTS AND TUITION