Leadership SRV Student Registration Form Student Registration for 2018-19 Class Personal Information First Name * Last Name * Cell Phone * Home Address * Home City * Home Zip * Personal Email * Home Phone What is your connection to the San Ramon Valley? * How many years have you lived or worked in the San Ramon Valley? * Do you expect to be living/working in this area in five years? Yes No What are your areas of particular interest for leadership involvement? ( education, human services, government other) What are your expectations and what do you hope to accomplish or gain from your Leadership San Ramon Valley experience? Employment Information Present Employer Your Title/position Work Phone Work Address Work City Work Zip Work Email Briefly describe your responsibilities What do you consider your greatest career achievements? What do you consider as your strengths? Additional employment/work experience Education Section School Name City Degree/Major School Name City Degree/Major Educational Achievements Community Involvement Organization Name Position Held Start/End Dates Describe your involvement How much time each month do you spend on community, civic, professional and other organizations and activities? Organization Name Position Held Start/End Dates Describe your involvement How much time each month do you spend on community, civic, professional and other organizations and activities? Time Committment In order to accomplish the program’s objectives and to realize maximum benefit, the full participation of each individual selected is necessary. Participation includes attendance at ten monthly sessions from 8 a.m. to 5 p.m. on the dates listed below. In addition, participants should expect from four to eight hours of outside preparation (interviews, research, group meetings, etc.) for most monthly classes. Participants missing more than two sessions will not graduate with the class. Sessions may be made up in subsequent years. September 6, 2018 October 4, 2018 November 1, 2018 December 6, 2018 January 10, 2019 February 7, 2019 March 7, 2019 April 11, 2019 May 2, 2019 June 6, 2019* *Final Class and Graduation Ceremony Tuition Tuition for each person accepted in Leadership San Ramon Valley is $1,095, which contributes to the cost of facilitators, meeting locations, meals and materials. This enrollment fee may be paid by any club, organization or business, or by the individual. An installment payment plan is available. A limited number of partial scholarships are available. Check all that apply Yes, I would like to request scholarship funding. My employer will sponsor (or partially sponsor) my participation in Leadership SRV An organization I am associated with will sponsor (or partially sponsor) my participation in Leadership SRV. Name of organization:An organization I am associated with will sponsor (or partially sponsor) my participation in Leadership SRV. Name of organization: Check if the sponsoring employer or organization is a non-profit Reference Section Full Name Relationship Phone Contact Full Name Relationship Phone Contact Full Name Relationship Phone Contact At which email address do you prefer to be contacted for class communications? Class material often includes attachments. If your work email typically blocks attachments, please consider choosing "personal" or "both." Radio Buttons Personal email address Work email address Both Submission APPLICATIONS MUST BE SUBMITTED ONLINE by JUNE 30, 2017. Contact the office below for more information or with questions. LEADERSHIP SAN RAMON VALLEY Post Office Box 1185 Danville, CA 94526 Phone 925.272-8553 Email: leadershipsrv@att.net www.leadershipsrv.org Please send me a copy of my submission. * Yes No reCAPTCHA Δ