Leadership Flathead Application

LEADERSHIP FLATHEAD
Application for the Class of 2021
Submit completed application by May 1, 2019.

(P) (406) 758-2810 [email protected]
Personal Information
Applicant Name*
First Last
Date of Application*
Applicant E-Mail*
Home Phone
Cell Phone
Home Mailing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Business Affiliation
Business or Association Affiliation
Applicant Job Title
Business Phone
Supervisor's Name
First Last
Supervisor's Title
I have been cleared by my supervisor to apply for the Leadership Flathead Class of 2021.
- Yes
- No
Business Mailing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Additional Info
Are You a US Citizen?
* Citizenship is NOT required for Leadership Flathead however it may limit participation of tours of security sensitive areas.
- Yes
- No
Vest Size
Food Allergies

Educational Background
Degree(s) Awarded
Professional Institution(s)
Training Program(s)
Leadership Activities
(List the major social, business or professional activities you have participated in during the past five years.)
Flathead Valley Issues
(List up to 3 major issues facing the Flathead Valley upon which you as a leader would like to effect change.)
Program Expectations
(How do you think Leadership Flathead can help you fulfill your aspirations as a leader?)

References
(List 2 individuals who may be contacted regarding your leadership qualifications.)
Reference #1
Name
Business or Affiliation
Email Address
Reference #2
Name
Business or Affiliation
Email Address

Tuition
Tuition
Tuition for Leadership Flathead is $1,300 per participant and is payable after acceptance into the program. Tuition must be received by July 15th. A 3% processing fee will be added to all payments made by credit card/debit card. Full Tuition for Leadership Flathead will be paid by:
- My Employer
- Me
Partial Scholarship
- I would like to be considered for a partial scholarship.
Please briefly state your need for a scholarship.
Leadership Flathead offers limited partial scholarships. Please provide an explanation of your financial need to the scholarship committee:

First Year:	Attend orientation (September 10, 2019) Attend an overnight retreat (September 19-20, 2019) Attend 9 monthly sessions scheduled October 2019 – June 2020 (Two excused absences are permitted.)
Second Year:	Help plan and present 2 monthly sessions for the Class of 2022 Attend your graduation ceremony in May 2021

*Please Note: Withdrawal by a participant from the program after July 31st will result in a 75% refund of tuition. After September 1st, refunds will not be issued. Credits may not be given for the next program year.
Signature*
By submitting this form, you consent to the use of your name, picture, silhouette, video reproductions of your physical likeness or verbal statements in print - for the marketing communications of Leadership Flathead.

Personal Information