Leadership Douglas 2024-25 Application BASIC INFORMATION First Name * Last Name * Home Address Address Line 1 * Address Line 2 City * State * Select option... Alabama Alaska Arizona Arkansas California Colorado Connecticut DC Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming DC Zip/Postal Code * Home Email * Cell * Date of Birth * Gender * Male Female Ethnicity * Live in Douglas County? * Yes No How many years have you lived in Douglas County? * Work in Douglas County? * Yes No How many years have you worked in Douglas County? * Are you applying as a business or an individual? * Business Individual PRESENT EMPLOYMENT Employer * Business Address Address Line 1 * Address Line 2 City * State * Select option... Alabama Alaska Arizona Arkansas California Colorado Connecticut DC Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming DC Zip/Postal Code * Business Phone * Business Email * Title or Position * Briefly describe your job responsibilities * Prefer email at home or business? * Home Business Both EMPLOYMENT HISTORY List in reverse chronological order. Employer 1 * Title * Period of Employment * Employer 2 Title Period of Employment COMMUNITY INVOLVEMENT/PROFESSIONAL AFFILIATIONS List your top three community and professional affiliations (the ones that mean the most to you). Name of Organization * Position Held or Role * Period of Affiliation * Name of Organization Position Held or Role Period of Affiliation Name of Organization Position Held or Role Period of Affiliation Are you enrolled or planning to enroll in other education programs at the same time as LD? * Yes No Do you have any work related training or travel which may conflict with LD? If so, what are the dates? * SHORT ANSWER ESSAYS Please attach a separate document to respond - limit 1 page total. What would you hope to gain from the Leadership Douglas program? In your judgement, list the three most important issues facing Douglas County and note why they are important to you. In your judgement, list the top three things you love about Douglas County and note why they are important to you. Upload Short Answer Responses * TUITION A tuition fee is required to cover materials, monthly program expenses, and both opening and closing retreats. If selected for participation, a minimum of 50% deposit is due at orientation in June, with the balance payable no later than July 25th. Tuition for Leadership Douglas is $1,700 for Douglas County Chamber members in good standing. Tuition is $2,000 for non-Douglas County Chamber members. TIME COMMITMENT Leadership Douglas has a mandatory time commitment for all 11 monthly, one-day sessions and both the overnight opening and closing retreats. Attendance at all programs is mandatory. In addition, there is a class service project and occasional homework assignments to go along with day programs. The time commitment is serious and participants not complying with the attendance requirements will be dropped from the program without tuition reimbursement. If selected, you and your employer must be willing to make a commitment of your time. (2024 Dates: June 20th, 3 - 6pm, Orientation/Retreat Preview; July 25th, 5 - 7pm, Introduction to Alumni/Alumni Social; August 22-23 Opening Retreat (tentative); September 5th; October 3rd; November 7th; December 5th; December 12th, Holiday Social. 2025 Dates: 1/9, 2/6, 3/6, 4/3, 5/1, May overnight Closing Retreat/Graduation date TBD.) ACKNOWLEDGEMENT * I have reviewed the 2024-25 Leadership Douglas Application and understand that the tuition cost is non-refundable should I not fulfill attendance requirements. I will attend all Leadership Douglas Program activities and look forward to being an active participant in the program. Applicant's supervisor and/or the CEO of the organization (or equivalent) is in support of the applicant’s participation in the Leadership Douglas Program. Upload Additional Documents * The applicant must upload the document with the signature of approval by the CEO or supervisor. Download the signature document here by copy and pasting the link into your browser: https://douglaschamberfoundation.sharepoint.com/:b:/g/EQafaqcluxhAhx92oS7AlTkBPm_66wHSKpWShHKAGb8-Ew?e=B4yP0m Completed application MUST be received by 3 p.m., Monday, May 6th. No applications will be accepted after the deadline.
