Leadership Wyoming Participant Application

Class of 2025

Submit by July 19, 2024

Applicants notified of acceptance by August 2

Program Starts August 29 - First meeting.

Class meets on the third Thursday of each month*

Questions:

Gina Suydam

Email: gina@wyccc.com

(570) 836-7755

*Please review all class dates at https://wyccc.com/leadership-wyoming-2 their are a few exceptions

Criteria for selection:

Demonstrated professional and/or personal leadership experience
Personal commitment to make a difference in Wyoming County
Goals for participating in Leadership Wyoming
A cross section of demographics

Name:*

First NameLast Name

Work Phone :*

Area CodePhone Number

Cell Phone :*

Area CodePhone Number

Business E-mail Address:*

Personal E-mail Address:*

We like to keep in touch with our alumni long-term having a personal email on record helps us if you leave your employer.

Date of birth*

This is STRICTLY to issue Continuing Education Units from Penn State University. No bearing on class acceptance.

Polo Shirt Size

Home Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Employer*

Your Title*

Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Supervisor*

Supervisor's Telephone :*

Area CodePhone Number

Supervisor’s Email*

Length of Time living in Wyoming County*

Length of Time working in Wyoming County*

Do you currently volunteer with an organization(s) in Wyoming County?*

YesNo

If Yes, Name of Organization(s)

How did you hear about Leadership Wyoming?*

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

Employment: Please describe your current occupation, including responsibilities, leadership roles and accomplishments.*

Describe two opportunities or challenges facing Wyoming 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?

Commitment Contract (Please read thoroughly.) This is a critical component of Leadership Wyoming; you and your employer must be fully aware of your commitment and responsibilities. The Chamber will also be reaching out to your supervisor to discuss expectations and commitment to the program.

Applicant Expectations

The following CODE OF CONDUCT & COMMITMENT CONTRACT expectations are required for each paticipant to commit to and carry out.

Check each box after reading, understanding, and agreeing to the statement.*

I understand it is mandatory to attend all Leadership Wyoming sessions and activities.I will complete and hand in all required LW course assignments by the specified date for each session.I will maintain my responsibility to my work obligations.I will keep my immediate supervisor aware of my progress on a regular basis.Appearance is an important part of one’s character and a social responsibility. I will uphold the dress code by following directions provided by the chamber for each sessions required attire.

APPLICANT EXPECTATIONS

The following section must be completed by the applicant highlighting your goals for participating in Leadership Wyoming.

EXPECTATIONS (Please list three)*

For the Applicant: I understand the purpose of Leadership Wyoming and, if selected, will devote the time and energy necessary to complete the program. I agree to abide by all provisions and commitments of Leadership Wyoming.

Applicant Signature*

Items to Be Delivered After Program Acceptance

1. Tuition

$795 check payable to Wyoming County Chamber of Commerce. Limited Scholarships may be be available for non-profit organziations, Please inquire at time of application about scholarship opportunities.

2. Waiver and Emergency Contact

3. Employer Commitment

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