Cohort 21 Civic Leadership Program Application

Cohort 21 Civic Leadership Program Application

Thank you for your interest in applying for the Gila Valley Leadership Network's Civic Leadership Program, a year-long induction into a network of leaders who work together to enhance their abilities to serve and strengthen our community.Gila Valley Leadership is organized in partnership with the Graham County Chamber of Commerce, City of Safford, Town of Thatcher, Town of Pima, Graham County, Mount Graham Regional Medical Center, and Eastern Arizona College with the generous support of numerous businesses and organizations in the Gila Valley, including Double R Communications, Kempton Chevrolet, Mount Graham Regional Medical Center, NatureSweet, OneAZ Credit Union, and the United Way of Graham and Greenlee Counties.
Instructions

Please complete each section below. All fields are required. Applications are due by 11:59 pm on Wednesday, July 15th. Interviews will take place on Thursday, July 16 and Saturday, July 18th For assistance in filling out this application online, set an appointment with Matt Valderramma-Svee, Team Assistant at the Graham County Chamber of Commerce, by emailing matt@grahamchamber.org‬. The committee will issue final decisions by 11:59 pm on Monday, July 20th.
Personal Information
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Best Cell Phone Number
This number should be able to text.Format: (000) 000-0000.
Best Email Address
example@example.com
LinkedIn (if available)
Emergency Contact

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Personal Limitations
To help us support your participation, please share any disabilities (temporary or permanent), allergies, medication sensitivities, dietary restrictions, or other medical considerations we should be aware of. This information is confidential and will be used only to provide appropriate accommodations. It will not affect your eligibility or selection for the program.
Professional Affiliation
Position
Organization
Organization Address
Organization Address
Organization Website
Please upload your resume

For help writing a resume, you may contact Eastern Arizona College's Career Service Center at alison.villalobos@eac.edu or ‭(928) 428-8609‬.
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Cohort Commitment

Please read and sign the commitment.
To qualify for induction, cohort members are expected to participate fully in the entire program, and attend all 9 Leadership Days, the Phoenix Delegation, and the induction ceremony. Delegates will also be asked to provide 20 hours of community service as part of their cohort year and a final report on their experience. Generally, participation requires one full day per month (8 am - 6 pm) for 10 months and a moderate amount of additional personal time working on cohort community service projects. Please examine the schedule at-a-glance below to determine if you can fully participate in the program.

Cohort 21 Schedule at a Glance, 8:00 am - 6:00 pm, Graham County Chamber of Commerce, 1051 W Thatcher Boulevard, Safford, Arizona, 85546:

Day 1: August 27, 2026
Day 2: September 24, 2026
Day 3: October 22, 2026
Day 4: December 3, 2026
Day 5: January 28, 2027
Phoenix Delegation: February 25 - 27
Day 6: March 25, 2027
Day 7: April 22, 2027
Day 8: May 27, 2027
Day 9: Induction Ceremony: June 24, 2027

If you cannot commit to these dates, please do not apply until you can fully commit to participating in the program.
I have read and understood the Cohort Commitment and Schedule at a Glance as explained above, and, if selected, I will honor that commitment.
Supervisor Permission

Participation in the Gila Valley Leadership Network's Civic Engagement Program requires prior authorization from your employer. If you are self-employed, please enter "self" for the name, phone number, and email address fields.
Supervisor's Name

First NameLast Name
Supervisor's Email Address
example@example.com
Supervisor's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fees

Gila Valley Leadership delegates or their employers are responsible for dues of $500.00. Scholarships are available based upon financial need and the availability of scholarship funds. Full payment of tuition is due no later than 11:59 pm on September 30, 2026.
My organization has a financial need, and I would like to be considered for a full scholarship for the program. I agree to give a presentation on my experience to sponsors if I am selected for the scholarship.
Acknowledgement of risk, media agreement, and release of liability.

I understand that my participation in the Gila Valley Leadership Network's Civic Leadership program may expose me to above normal risks due to travel, touring of area agriculture, mining, and government facilities, and participation in team building exercises and encounters with other natural and man-made hazards. I also understand that although the Gila Valley Leadership Network's Civic Leadership Program (a leadership development program administered by the Graham County Chamber of Commerce) will take precautions to provide proper instruction and supervision, it is impossible to guarantee absolute safety. I also understand that I share the responsibility for safety during the program and I assume that responsibility. If at any time I feel uncomfortable with an activity, I can exercise my right to withhold participation. I have in place personal health insurance and am responsible for any medical expenses that may arise as a result of accidental injury during participation. I understand that parts of the program may be physically or emotionally demanding. I affirm that my health is good, and that I am not under a physician’s care for any undisclosed condition that bears upon my fitness to participate. I understand that each participant must assume the risk of physical injury that could result from any of the activities. I hereby release Gila Valley Leadership and the Graham County Chamber of Commerce, its staff members, board and committee members, volunteers, financial supporters, and general members from all liability for any injury to me from participation in the Gila Valley Leadership Network's Civic Leadership program.
I understand that these terms shall serve as a release of liability for my heirs, executors, administrators, and all members of my family. I understand that photos and videos of my face and my name will appear on websites, press releases, news organizations, and newsletters, and I agree to release my image and name.
Click Submit

If you have completed all the sections above, please click "Submit" below.
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Cohort 21 Civic Leadership Program Application

Instructions

Personal Information

Professional Affiliation

Cohort Commitment

Supervisor Permission

Fees

Acknowledgement of risk, media agreement, and release of liability.

Click Submit

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