Leadership Colquitt County Application

Basic Information

Name*

First NameMiddle NameLast Name

Address*

Home Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Birth Date*

MonthDayYear

Gender*

How long have you lived in Colquitt County? *

How did you hear about Leadership Colquitt County?*

If someone referred you to our program, please tell us who?

Describe two opportunities or challenges facing Colquitt County in the next decade and give some thoughts about how you can help address them.*

What do you hope to gain from this program?*

Employment

Present Employer:*

Title:*

Business Address: *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Length of employment: *

Briefly describe your responsibilities in your employment: *

Educational Background

Please list the name and location of the institution, degree awarded (if applicable), and years attended.

High School or GED (name of educational institution):*

Post-Secondary Education (college, technical college, etc.):*

Advanced Degree(s):

List special recognition/certificates/achievements: *

Community Involvement

Please list any community involvement or professional affiliations (civic, government, political, religious, and social). Indicate the name of the organization, your position, and your responsibilities. Please elaborate on any significant leadership position(s) or recognition in the business or professional area:

Organization:*

Positions Held:*

Responsibitites:*

References

Please list two professional references, that are not family members, who can attest to your present and/or potential leadership ability:

Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Relationship*

Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Relationship*

Transportation & Liability Waiver

In consideration of agreeing to participate in the Leadership Colquitt County program, the Participant hereby releases the (i) Moultrie-Colquitt County Chamber of Commerce (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 Colquitt County 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 Colquitt County 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 Colquitt County and is also aware of the potential risk and dangers inherent in workplaces and other locations the Participant may visit during the Leadership Colquitt County 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 Colquitt County 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 Colquitt County program, Participant agrees to indemnify and hold harmless Moultrie-Colquitt County Chamber of Commerce 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.*

YesNo

Photograph & Media Release

I understand that photographs and videos may be taken of the participants during the Leadership Colquitt County program. I consent to such photographing and videotaping for the use by Leadership Colquitt County 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 Colquitt County and other activities of the Chamber.

I have read, understand, and agree with the statement above.*

YesNo

Copy of your photo ID:*

Program Requirements, Commitment of Attendance, Tuition

The Leadership Colquitt County (LCC) program will require participation from August 2024 until May 2025. The program consists of a kickoff ceremony, 8 full day sessions and a community volunteer project that will be determined during the Kickoff Session. The LCC Program will conclude with a Graduation and reception.

Participation in at least 9 of the 10 sessions, as well as participation in one community volunteer session will be required to graduate from the Leadership Colquitt County program. Roll is taken at the beginning and end of each morning and afternoon session, each of which counts as ½ day (.5 day). If an absence is necessary, a total of 1 day or 2 half days for the nine sessions will be excused. A late arrival or early departure of 30 minutes or more will constitute a ½ day absence. Participants with absences that exceed this policy will be dropped from the class. All requests for non-emergency absences must be submitted for approval via email to Caitlyn Hatcher at president@moultriechamber.com no less than three business days prior to the session.

Application deadline is Friday, July 19, 2024.

Tuition for the 24’ & 25’ Leadership Colquitt County Program is $600 per person and must be paid by check, cash, or credit card no later than Friday, August 16, at 12 noon. Tuition covers all the program costs including Kickoff and Graduation, materials, instructors, and meals. Travel to sessions is participant’s responsibility. If an applicant cancels prior to September 18th, $100 of tuition will be forfeited. If an applicant cancels after September 18th, $250 of tuition will be forfeited.

Do you agree to the program requirements, attendance, and tuition policy as stated above?*

YesNo

Do you have the full support of your employer for the time required to participate in the 2024-2025 Leadership Colquitt County program?*

YesNo

Employer or Direct Supervisor's Signature:*

Email*

example@example.com

Applicant's Signature: *

Date:*

Please list any food allergies:*

Additional Comments

The Chamber will be in contact with you prior to program acceptance to review your application and chamber expectations.

For any questions or concerns, please contact Jasmin Luna @ programservices@moultriechamber.com or (229) 985-2131.