Leadership Sandusky County

Date:
First Name: *
Last Name *
Preferred Name/Nickname
Home Address:
Home E-mail:
Length of Residence/Employment in Sandusky County:
Current Employer:
Address:
Telephone Number:
Email:
Present Title or Responsibility:
Since:
COMMITMENT FOR PARTICIPATION:
In order for Leadership Sandusky County to accomplish its mission and objectives, the full participation of each individual selected is required. This includes one full day per month of the program, orientation, graduation, and participation in a service project with your fellow classmates. Attendance is required at a minimum of 7 of the 9 monthly sessions, with the class project, orientation and graduation mandatory. Will you be able to fulfill these commitments?
Participation Consent *	Yes No
SPONSOR: (Employer, Spouse, Pastor, etc...)
This candidate has my full support to participate in Leadership Sandusky County.
Name:
Title:
Date:
Organization:
Do you have the full support of your employer for the time required to participate?	Yes No
ADDITIONAL REFERENCE:
Name:
Relationship:
Phone:
AGREEMENT:
I understand and share the goals of the Leadership Sandusky County program. If selected, I will devote the required time to fulfill the commitments identified above.
Digital Signature *
* Please type your full name into the field marked "Digital Signature". This field serves as a digital (electronic) copy of your signature and confirms your acceptance of the agreement listed above. This signature also serves as your endorsement stating that all information supplied by you is complete and accurate to your knowledge.
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I understand that photographs taken in association with the Leadership Sandusky County class and activities may be used in future promotional materials, such as presentations, web site, brochures, etc…
Photo release *	I accept that my photograph may be used in promotional materials I decline that my photograph be used in promotional materials.
Digital Signature for Photo Release *
* Please type your full name into the field marked "Digital Signature". This field serves as a digital (electronic) copy of your signature and confirms your acceptance of one of the photo release agreement options listed above.
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FINANCES
Tuition for each participant is $400.00 and payment is due on or before the orientation date. Cash and check payments are accepted.
APPLICATION PROCESS
Submit online application and a mail $20.00 non-refundable processing fee; this processing fee does not go towards your tuition. Make checks payable to Leadership Sandusky County and mail to 101 S. Front St., Fremont, OH 43420
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