2027 Grow Clinton Leadership Institute Application

2027 Grow Clinton Leadership Institute Application

Please complete the application and sign where indicated.
Applicant Information

Personal Information
Name

First NameLast Name
Home Address - Street
Home Address - City
Home Address - Zip
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Years living/working in the Clinton Region
Personal Email Address
example@example.com
Emergency Contact Name & Number
Employment Information

Current Position
Business Name
Business Street/Box
Business City
Work Email Address
example@example.com
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Position/Job Title
Length of employment
Describe current role/responsibilities
Supervisor or Contact Person Name

First NameMiddle NameLast Name
Supervisor or Contact Person Title
Supervisor or Contact Person Phone
Please enter a valid phone number.Format: (000) 000-0000.
Supervisor or Contact Person E-mail
example@example.com
Community Involvement

Tell us a little bit more about you
What strengths, experiences and/or leadership would you bring to the program?
What do you hope to gain from your participation in the course?
What is one area where you would like to see growth or change in Clinton County in the next 5 years?
Community Involvement - Organization / Positions Held / Dates
Community Involvement - Organization / Positions Held / Dates
Community Involvement - Organization / Positions Held / Dates
Areas of interest and/or future community involvement
Conditions, Agreement, & Signatures
By submitting this application to the Grow Clinton Leadership Institute, the applicant indicates a commitment to:

1. Attend all sessions and graduation (to take place in June at the Annual Meeting). Participants missing more than two sessions will be asked to leave the program. Please try your best to avoid other commitments during class time.

2. Participate in the assigned homework and class sessions.

3. Seek out and accept greater community leadership roles upon completion of the program.

Leadership Institute participants are expected to attend all sessions and fully commit to activities and assignments that aid in the learning process. The course requires commitment from the participant and their employer.

I understand the commitment required to succeed in the Grow Clinton Leadership Institute. If selected, I will devote the required time as listed above and support the goals of the Grow Clinton Leadership Institute Program.

2027 Tentative Class Dates:

January 12, 2027 (Kick-Off Luncheon)	March 23
January 26	April 6
February 9	April 20
February 23	May 4
March 9	May 18

*All dates are subject to change

Applicant’s signature
Applicant’s signature - Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Supervisor’s signature
Supervisor’s signature - Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Who will be responsible for your tuition?

Other
Scholarship need explanation
A limited number of partial scholarships may be awarded. If interested, please explain your needs. Full tuition for Leadership Institute is $500.
Upon submission, you will receive formal notification regarding your acceptance into the program.
Should be Empty:

2027 Grow Clinton Leadership Institute Application

Applicant Information

Employment Information

Community Involvement

Conditions, Agreement, & Signatures