Leadership Douglas 2021-22 Application

BASIC INFORMATION

First Name *

Last Name *

Home Address

Address Line 1 *

Address Line 2

City *

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? *

PRESENT EMPLOYMENT

Employer *

Business Address

Address Line 1 *

Address Line 2

City *

Zip/Postal Code *

Business Phone *

Business Email *

Title or Position *

Briefly describe your job responsibilities *

Prefer email at home or business? *

Home Business

EMPLOYMENT HISTORY

List in reverse chronological order for last 10 years.

Employer 1 *

Title *

Period of Employment *

Employer 2

Title

Period of Employment

Employer 3

Title

Period of Employment

BUSINESS/PROFESSIONAL AFFILIATIONS

If any - last three years only. (Use Community Involvement section for civic organizations, public office or political activities.)

Name of Group 1 *

Position Held or Assignments *

Period of Affiliation *

Name of Group 2

Position Held or Assignments

Period of Affiliation

Name of Group 3

Position Held or Assignments

Period of Affiliation

Most significant career achievement thus far? *

COMMUNITY INVOLVEMENT

If any - last three years only. (Civic, public, religious and community involvement, etc.)

Name of Group 1 *

Position Held or Assignments *

Period of Affiliation

Name of Group 2

Position Held or Assignments

Period of Affiliation

Name of Group 3

Position Held or Assignments

Period of Affiliation

Recognitions for special contributions?

SPECIAL AWARDS AND/OR HONORS & RECOGNITIONS

List below

EDUCATION

High School *

College *

Degree *

Graduate School

Degree

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? *

SHORT ANSWER ESSAYS

Please attach a separate document to respond - limit 1 page total.

Why do you feel community involvement is important?

What would you hope to gain from the Leadership Douglas program?

In your judgement, list in order the three most important issue facing 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 retreat. If selected for participation, a minimum of 50% deposit is due at orientation in May, with the balance payable no later than June 25th. Tuition for Leadership Douglas is $800 for DC Chamber members in good standing. Tuition is $1,000 for non-DC Chamber members, which includes a one-year individual DC Chamber membership.

TIME COMMITMENT

Leadership Douglas has a mandatory time commitment for all 10 monthly, one-day sessions and an overnight retreat beginning August 2021. Attendance at all programs is mandatory. In addition, there is a class service project, book study, and occasional out-of-class 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 aand your employer must be willing to make a commitment of your time. (2021 Dates: May 19, 4 - 6pm Orientation; July 27th, 5 - 7pm Introduction to Alumni; August 25-26 Retreat; October 7; November 5; December 9; December 9 Holiday Social. 2022 Dates: 1/5, 2/3, 3/3, 4/14, 5/5, May Graduation date TBD.)

ACKNOWLEDGEMENT *

I have reviewed the 2021-22 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: https://douglascountygeorgia.com/wp-content/uploads/2020/01/Leadership-Douglas-Application-Approval-document-1.pdf

Completed application MUST be received in Chamber office by 5 p.m., Friday, March 12th. No applications will be accepted after the deadline.

Leadership Douglas 2021-22 Application

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