YOUTH Leadership Colquitt County Application

Basic Information

Name*

First NameMiddle NameLast Name

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Address*

Home Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Birth Date*

MonthDayYear

Gender*

Parent/Guardian's Name *

First NameLast Name

Work Phone*

Please enter a valid phone number.

Cell Phone*

Please enter a valid phone number.

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

What do you hope to gain from this program?*

Employment (if applicable)

Current Employer:

Supervisor's Name:

Phone Number

Please enter a valid phone number.

Length of employment:

__ yrs. __ mos.

Hours per week:

Applications are due by Friday, June 20th at noon. Please make sure you have included the following:

Will you be able to attend at least seven of the scheduled sessions?*

YESNO

Applicant's Signature*

Date*

Date

Recommendation Form Please include one completed recommendation form with your application Click here for form.

Important: Recommendation forms will not be accepted by family members. Acceptable references may include: 1. A school official (e.g., teacher, counselor, coach) who interacts with you regularly 2. An adult who knows you well, such as community leader or employer

File Upload

Activities/Honors/Awards/Interests On a seperate sheet, please list the following:

School, civic, or church related activities in which you are currently involved
Any special interests or hobbies
Honors or awards you have recieved

File Upload

Commitment to the Program Please provide a one-page, typed, and double-spaced essay outlining:

What you hope to gain from participating in the LCC Program
What unique contributions you believe you will bring to the program

File Upload

Program Requirements The LCC program runs from August 2025 through May 2026. The program includes nine sessions, one of which is a full day visit to the State Capitol Building, and one community volunteer session, scheduled during the Kick-off Session.

Class Time: 8:30AM - 4:30PM (Note: Most sessions will conclude earlier, but a few may last the full day)
Age Requirement: Applicants must be at least 16 years old
Attendance: Participants must attend at least 7 of the 9 sessions and complete one community volunteer session to be eligible for graduation

For any non-emergency absence, requests must be submitted via email to Caitlyn Hatcher at president@moultriechamber.com no later than 3 business days prior to the missed session.

Interviews & Tuition All applicants will be interviewed by the Leadership Colquitt County selection committee, which includes members of the steering committee. Interview dates and times will be communicated after the application deadline.

Applicants accepted into the 2025-2026 Leadership Colquitt County program must pay a $50 tuition fee by Friday, August 15th at 5PM.

Deadline to apply is Friday, June 20th.

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

YesNo

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

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.