Application Form

"*" indicates required fields

Title*

First Name*

Middle Initial (or Name)

Last Name*

Suffix

Race*

White

Black or African American

Latino / Hispanic

American Indian or Alaskan Native

Asian

Native Hawaiian or other Pacific Islander

Multiple Races

Another Race

Prefer not to answer

Gender*

Man

Woman

Transgender woman

Transgender man

Non-Binary

Another

Prefer not to answer

Contact Information

Primary Email*

Primary Email Type*

Personal

Business

Alternate Email (If Applicable)

Alternate Email Type

Personal

Business

Cell Phone*

Home Phone (If different than cell)

Home Address

Address*

Street Address Address Line 2 City State ZIP Code

Home Zip +4

Employment Information

Currently Employed*

Yes

Self Employed

Employer/Company Name*

If not currently employed enter the name of your last employer.

Position/Title*

If not currently employed enter your last position/title held.

Address*

Street Address Address Line 2 City State ZIP Code

Work Zip +4

Work Phone

Phone Extension

(If Applicable)

How long have you lived/worked in Rockland County?*

Leadership

Please list any leadership experience, including organizations and positions held.*

Please list any awards, honors, or special recognitions you have received for your leadership experiences.*

What you consider your strongest leadership attributes?*

Service

Please list your community services activities/ or volunteer commitments for the last ten years. Please include positions held and your length of service for each organization.*

Are any of your community service/volunteer activities related to your employment? If yes, please explain.*

What do you consider your most significant service experience?*

Essay

Please explain in 250-500 words.

In your opinion, what do you believe to be the most important issue or concern facing Rockland County?*

Supplemental Information

Why do you want to participate in the Leadership Rockland program and what do you hope to get out of the program?*

List any additional information you feel is relevant to your application that you would like us to know and consider.

How did you learn about Leadership Rockland?*

Alum Employer

Social Media

Direct Recruitment

LR Director

Other

Check all that apply

If other, please explain*

Scholarship Information

Leadership Rockland offers a limited number of partial scholarships for applicants who require financial assistance. We encourage applicants to also seek funding from other sources.

Do you have a financial need for a partial scholarship?*

Yes

If you are not awarded a scholarship, will you still be able to participate in the program if accepted?*

Yes

Please explain the circumstances that make you apply for a scholarship based on need.*

Additional Application Materials

Résumé

Please upload a copy of your résumé/CV/bio

Resume

Accepted file types: doc, docx, pdf, Max. file size: 512 MB.

References

Applicants must submit at least two (2) personal recommendations from people who are knowledgeable about your leadership performance or potential. The best applications will have recommendations from different organizations. Please limit recommendations from Leadership Rockland board of directors to one. (See list at http://www.leadershiprockland.org/about/board-of-directors/.)

Please provide the names and email addresses of the two people you have asked to provide a recommendation. Please advise your references that Leadership Rockland will email them the recommendation link directly.

Reference #1*

Reference #1 Email*

Reference #2*

Reference #2 Email*

Application Fee or Waiver

There is a $25 non-refundable application fee to apply to the program. This fee may be waived in whole or in part for those who have paid to attend any Leadership Rockland events between September 1st of last year and May 1st of this year.

Based on the above, are you eligible for the application fee waiver?*

Yes

If yes, what event(s) did you attend? Include approximate date and location.*

Payment

Payment of the application fee can be made online (preferred method). Payment can also be made by check payable to Leadership Rockland, Inc. Please indicate below which payment method you intend to use. After you submit your completed application, you will receive further details on paying the application fee.

Payment Method*

Online (Preferred Method)

Check by mail

Sign and Submit Application

If you are willing to make a commitment to attend each of the 11 sessions from September through June, and you understand the tuition requirements, please so indicate with your signature. By signing you understand that you are committing to the terms of the program participation. By checking this box each party agrees that the electronic signatures, whether digital or encrypted, of the Applicant submitting this Application are intended to authenticate this writing and to have the same force and effect as manual signatures.

Signature Acknowledgement*

Print Full Name*