Leadership Northern Kentucky           Class of 2012 Application

INSTRUCTIONS
  • Please complete each section in full, limiting answers to the space available. Completed applications must be returned with a check for $2,000 Chamber members, $2,300 non-members, no later than Fri. June 17, 2011.  The Class of 2012 will be announced by Fri. July 1, 2011.  The check should be made payable to Leadership Northern Kentucky and mailed to Northern Kentucky Chamber of Commerce, P.O. Box 17416, Fort Mitchell, KY  41017, Attention: Ruth A. Eger. 
  • Applicants not selected will have their payments returned shortly thereafter.
  • Please provide one formal color headshot suitable for publication.  The minimum size is 4" x 5".  The application is incomplete without the photo. You may mail this with your check or send via email to reger@nkychamber.com
  • PLEASE NOTE:  This document must be completed in one sitting.  It cannot be saved before submitting.  A word document is available if that is more convenient for you, please request one via email to reger@nkychamber.com

PROGRAM SELECTION
  • Participation in Leadership Northern Kentucky is open to persons living and/or working in Northern Kentucky and Greater Cincinnati area.
  • Since the number of participants to Leadership Northern Kentucky is limited (approximately 40 - 45 participants) and the number of applications received far exceeds the number of selected participants, applicants who are not selected are encouraged to reapply in subsequent years.
  • Participants will be selected by the Leadership Northern Kentucky Selection Committee based upon information completed on the application and the confidential references supplied. The Committee will be seeking representation from a cross-section of the community. Participants will be active in business, education, the arts, religion, health care, government, community-based organizations, ethnic and minority groups and will reflect the diversity of the community.
  • Applicants must have the full support of the company or organization they represent, as well as their employer or supervisor. Attendance at the retreat and monthly meetings is mandatory. Tuition for the Class of 2012 is $2,000 for Chamber members and $2,300 for non-members.   If seleceted, tuition is non-refundable.
 
PERSONAL DATA
Last Name*
First Name*
Middle Name:
Preferred First Name for Name Tag
Home Address*
City*
State*
Zip*
Home Phone*
Home E-mail
Business Address
City
State
Zip
Business Phone
Business E-Mail
Mobile Phone
Spouse Name

Any Special Food Requirements

OPTIONAL PERSONAL DATA
(this information will assure class diversity)
Sex
Date of Birth
Place of Birth
Race

Years lived in region

Hobby

.
EDUCATION
High  School
Name of School
From
To
Degree/Major
College  
Name of School
From
To
Degree/Major
Graduate
Name of School
From
To
Degree/Major
Continuing Education
Name of School
From
To

Degree/Major

EMPLOYMENT
Current Employer
Title/Responsibility
Start Date
Since
Previous Employer
Employer 1
Start Date
End Date
Title/Responsibility
Employer 2
Start Date
End Date
Title/Responsibility
Employer 3
Start Date
End Date

Title/Responsibility

INVOLVEMENT
Include athletic, business, civic, community, government, political, professional, religious, social, or other activities. Indicate major rolls in the organization at this time.
Organization 1
Responsibilities
Organization 2
Responsibilities

What do you consider to be your most important community service accomplishment to date?

GENERAL INFORMATION
1. What do you hope to gain as a participant in Leadership Northern Kentucky?*
2. What is the most significant leadership quality necessary to bring about positive change within the Region?*
3. What are the two most pressing issues facing Northern Kentucky and/or our Region today?*
4. Have you ever applied to Leadership Northern Kentucky before?*
If Yes, what year
5. Will you need special accomodations because of a disability/diet?*
If Yes, please descibe
6. What qualities do you feel you can bring to the success of the program?*

7. The program is a lot more fun than the application, so please provide some fun facts about yourself; nickname; favorite food; favorite trip; favorite book or movie.

REFERENCES
All applicants are required to submit three (3) confidential references. One reference must be your employer, unless your own the company. References must be submitted using our online referral form and you are responsible in forwarding that form to them.  Personal letters of recommendation will not be accepted.  The Chamber must receive this information by 5 p.m. on Friday, June 17, 2011. Please indicate those submitting references.
Reference 1*
Phone*
Reference 2*
Phone*
Reference 3*
Phone*
SCHOLARSHIPS
Limited scholarship funding is available and are primarily for our non-profit applicants.
If accepted, will you find it necessary to seek scholarship assistance towards the tuition fee, and if so, how much?
If Yes, Amount $ (not to exceed $1,000 Chamber members, $1,300 non-members) Assistance toward tuition fee Yes, How Much?


NOTE: Each scholarship recipient must pay or raise a minimum of $1,000.

COMMITMENT

  • Attendance at all sessions is expected for graduation from the program. (One excused absence is allowed.) Participants missing more than one session may be asked to withdraw from the program and tuition shall not be refunded.
  • Retreat (September 15 & 16, 2011). This requires an overnight stay.
  • Sessions are one full day per month, September through May, plus half day pre-sessions for some days. Monthly sessions run from 7:30 a.m. to 5:30 p.m. Block out the entire day on your calendar!  
  • Sessions (with preliminary dates) can be viewed online.
Please indicate your acceptance of this commitment by clicking the Submit button below. You are committing to attend all of the sessions, including the overnight retreat. You also realize that this commitment is for the entire day (7:30  a.m. - 5:30 p.m.) of each session.
Please click submit only one time.  The transaction may take several seconds.