Limestone Coast Leadership Program Application Form
Personal Details
Title
Mr.
Mrs.
Miss.
Ms.
Dr.
Full Name
Preferred Name
Sex
Male
Female
Age
18-25
25-30
30-35
35-40
40-45
45-50
50-55
55-60
60-65
65-70
70-75
Postal Address
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Contact Details
Email
Phone
Language & Culture
In which country were you born?
Your nationality
Do you speak a language other than English at home?
Yes
No
(if more than one indicate the one that is spoken most often)
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Hobbies & Interests
Main personal hobbies and interests?
Employment / Experience
Current title / position
since
Title / position on joining
Date begun
Brief description of current responsibilities (role, budget, staff, leadership etc)
Previous employment (up to 1- years in reverse chronological order)
What do you consider your highest career achievement / experience to date?
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Education / Training Background
Highest level of education (School or Qualification)
Any special awards / honours / prizes
Indicate any leadership training / courses / subjects you have completed via studies, employment or voluntary work
Will you be enrolled for any formal qualification next year?
Yes
No
If yes please specify
Social Media
What social media forums do you use?
In what capacity?
Professional
Recreational
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Activities and Organisations
Please list in order of importance to you, up to three community, civic, professional, business, religious, social, sports and other organisations of which you are, or have been, a member indicating any positions of responsibility (include organisation, dates of membership and position held)
How much time each month do you currently commit to the above organisations or equivalent activities
What do you consider your most important achievement in any of the above organisations? Why?
If you have previously not had the time or opportunity to become actively involved, what have been the major barriers to becoming involved?
What kinds of community activities would you like to pursue in the future?
Awareness
What do you feel are the two most significant problems we are facing in the Limestone Coast today and what do you feel needs to be done about one of them?
What are the two most exciting opportunities available to the Limestone Coast and what do you feel needs to be done to develop one of these?
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Personal
What are your reasons for nominating for the Limestone Coast Leadership Program?
Why should you be selected for this program?
What particular strengths and experiences would you bring to the program?
How would you expect the broader community to benefit from your successful completion of the program?
Participation
Attendance
I will be able to commit to the programs requirements (refer to website for "what is expected of participants").
Yes
No
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Participant Fee - Program Cost and Scholarships
The fees for the 2019 LCLP are $7,000 (+GST). Full payment will be required within 30 days of invoicing or a payment plan can be requested.
Do you have your employers support to participate in this program (where required)
Yes
No
If requested, can you provide personal recommendations/referees in the future
Yes
No
Scholarships
Do you wish to be considered for a scholarship?
Yes
No
Would you consider a part or half scholarship?
Yes
No
How did you hear about the program?
We have a number of generous partners who are offering scholarships to people who, by their participation in the LCLP, will add important diversity of background and experience to the program group but may not have the means to pay the full program fee.
In conjunction with our partners, the Limestone Coast Leadership Program Steering Committee will determine scholarships recipients, considering criteria consistent with the programs philosophies, and is not required to provide reasons for its decision.
What Limestone Council are you from?
Submission of this application will represent your understanding of the programs conditions and your electronic signature for this application. Do you understand and agree
Yes
No
Would you still like to be considered for the program (full payment or payment plan) if you are not successful in gaining a scholarship?
Yes
No
Are you fully aware of the time commitment and program requirements
Yes
No
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