2021-2022 Leadership Fort Dodge Application

Name*

First NameLast Name

Company*

Company Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

E-mail*

Cell Phone *

Area CodePhone Number

Work Phone *

Area CodePhone Number

Shirt Size*

Please list any special accommodations needed (dietary or otherwise):

Employer Contact*

First NameLast Name

Title*

Employer Phone*

Area CodePhone Number

Employer E-mail*

Participant: Why do you want to participate in the Leadership Fort Dodge program?*

Participant: What areas of the community are you most interested in learning about and why?*

Program Dates:

Classes are held on the 2nd Thursday of each month, September through May, with the potential exception of the February class. Classes are 8 am to 5 pm with the possibility of an early start time. Dates for the 2021-2022 sessions include:

Tuesday, August 31, 2021 – Lunch Orientation

Thursday, September 9, 2021

Thursday, October 14, 2021

Thursday, November 11, 2021

Thursday, December 9, 2021

Thursday, January 13, 2022

Thursday, February 10, 2022 (subject to change)

Thursday, March 10, 2022

Thursday, April 14, 2022

Thursday, May 12, 2022

Tuesday, May 17, 2022 – Graduation

** Please note the attendance policy applies for each of these sessions.

Participant Expectations and Program Requirements:

Participants will be randomly assigned to a committee to help plan one of the Leadership sessions. Each class member is expected to be an active participant in planning this session.
Each participant is expected to attend one Fort Dodge City Council meeting or Webster County Board of Supervisors meeting.
Each participant must complete one volunteer activity or act of community service during the course of the program.

Attendance Requirements:

Each participant is allowed one full absence during the duration of the program.
Participants who have more than one absence, but no more than two, will be given the opportunity to make up the absence with an additional service project.
Any no call/no show may result in immediate removal from the program.

By signing and submitting this application, I acknowledge receipt of the above attendance policy and understand what is expected of me as it relates to Leadership Fort Dodge and attendance. I also agree to pay the fee of $300 and understand that refunds will not be issued to participants who fail to meet the expectations of the program or who leave the program following the September 5 orientation.

Applications are not considered complete until both the application & $300 fee are received.

Participant Signature*

Participant Printed Name*

First NameLast Name

Employer's Signature*

Employer's Printed Name*

First NameLast Name

Company Name*

Date*

MonthDayYear