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Application Form
Step 1 of 6
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PERSONAL INFORMATION
First Name
*
Middle Name
*
Last Name
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Nick Name
Gender
*
Male
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Race
Birthdate
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Home Address
*
Street Address
City
ZIP Code
Email Address
*
Years in St. Tammany Parish
*
Please enter a value between
1
and
99
.
Home Phone Number
*
Mobile Phone Number
*
Spouse’s Name
Children
*
None
One
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Nine
Ten
How Many are Under 18?
None
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Nine
Ten
Have you ever served in the Military?
*
No
Yes
Dates Served
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From
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to
Highest Rank
*
Emergency Contact Name
*
Emergency Contact Number
*
Photo
*
Accepted file types: jpg, gif, png.
Upload a photo of your self. Please limit the file size to 500k or less.
Upload in jpeg format.
EMPLOYMENT
Present Employer
*
Date Hired
*
Month
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1978
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Mailing Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Business Phone
*
Business Fax
*
Business Email
*
Present Title
*
Since
*
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Preferred mailing address
*
Home
Work
Previous employment in reverse chronological order
*
Employer
Title/Responsibility
From
To
EDUCATION
Briefly summarize your educational background. Optional. List degrees/certificates received, field of study, vocational training programs, professional institutes, etc. List extracurricular activities and special honors received.
ORGANIZATIONS / ACTIVITIES / INVOLVEMENT
Please list volunteer organizations of which you have been a member and that have been of significance to you.
*
Organization
Position(s) Held
Describe Responsibilities
How much time each month do you commit to this organization?
COMMUNITY INVOLVEMENT
What do you consider your most important accomplishment in one of the above organizations? If you have not had the time or interest to become actively involved, what conditions have changed that now enable you to seek involvement in the community?
*
COMMUNITY NEEDS
In your judgment, what is the most pressing problem facing St. Tammany Parish today?
*
Why do you want to attend Leadership St. Tammany?
*
Briefly describe a leadership challenge you have experienced or handled.
*
Any added comment?
COMMITMENT
To graduate from Leadership St. Tammany, a participant is expected to attend all of the sessions. No more than 9 cumulative hours can be missed. If more than 9 hours are missed, you will be required to make it up the following year. Missing 27 or more hours will disqualify participants from making up the missed sessions and completing the program. Graduates will receive a certificate of completion upon meeting program requirements.
Participation at the opening weekend retreat is mandatory for participation in the program. Attendance at the entire retreat is required.
One full-day (9 hour) session per month, September through May, usually the second Wednesday
The closing session is for four hours on an evening in May
Will you be able to fulfill this commitment?
*
Yes
No
Do you have the support from your employer for the time involved?
*
Yes
No
Please provide your supervisor’s contact information
Who recommended Leadership St. Tammany to you?
How did you hear about Leadership St. Tammany?
Have you previously applied to Leadership St. Tammany and when? (May be multiple years)
Tuition for each participant is $1,250. $100 is required with this application form. (This is refundable if not selected) Note: At least $100 of the tuition is required to be paid personally by the participant.
Will you be able to fulfill this financial commitment?
*
Yes
No
A limited number of partial scholarships are available. If accepted to the Leadership St. Tammany Program, will you find it necessary to seek financial assistance from the Program toward the tuition fee?
*
Yes
No
I understand the purpose and commitments of the Leadership St. Tammany Program; and, if I become a participant, I will devote the required time. I understand that more than nine cumulative hours of absences will mean that I will not graduate with my original class. The missed session(s) can be made up the following year, and a certificate will be received at the end of that year.
Signature
*
Date
*
Application Fee
Upon clicking submit below you will be taken to Paypal to process the $100.00 application fee. Applicants who do not pay the $100.00 application fee will not be considered. The application fee will be refunded if you are not selected.
Leadership St. Tammany Application Fee
Price:
$100.00
Phone
This field is for validation purposes and should be left unchanged.
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