Adult Application Online Application Please complete the online application. You may submit up to four (4) supporting documents. Please send those documents or any questions via email to contact@leadershiphs.org. Please enable JavaScript in your browser to complete this form.1234567Name *FirstLastPreferred TitleMr.Ms.Mrs.MissDr.OtherHome AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePrimary Phone *Your preferred contact number.Mobile Phone *A secondary number where we can reach you.Email *Spouse's NameFirstLastIf applicable.Reference #1 *FirstLastReference #1 Phone *Relationship to #1 *Reference #2 *FirstLastReference #2 Phone *Relationship to #2 *NextEDUCATIONBegin with high school; then list college(s); business, trade schools, and/or other specialized training.High School Name *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeStart DateEnd DateSchool #2 *College or university; accreditation program, trade schools, and/or other specialized training.Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeStart DateEnd DateDegree or Certification EarnedMajor/Minor or Specialty/FocusSchool #3 NameCollege or university; accreditation program, trade schools, and/or other specialized training.School #3 AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeStart DateEnd DateDegree or Certification EarnedMajor/Minor or Specialty/FocusSpecial Awards or Honors for Academic PerformanceNextEMPLOYMENTPlease begin with your current employer, then list workplaces in reverse chronological order. Current Employer *Date Employment BeganCurrent Title or ResponsibilityName of Previous Employer #1Start Date (Previous Employer #1) End Date (Previous Employer #1)Title & Responsibilities (Previous Employer #1) Name of Previous Employer #2Start Date (Previous Employer #2) End Date (Previous Employer #2)Title & Responsibilities (Previous Employer #2) NextCOMMUNITY ACTIVITIESList key community, civic, professional, busines, religious, social, or other organizations you have been involved in within the past five (5) years. Organization #1Please provide the organization name, dates of membership, and position(s) held.Organization #2Please provide the organization name, dates of membership, and position(s) held.Organization #3Please provide the organization name, dates of membership, and position(s) held.Organization #4Please provide the organization name, dates of membership, and position(s) held.Organization #5Please provide the organization name, dates of membership, and position(s) held.NextAWARDS & HONORSPlease list any special awards or honors you've received for education or leadership activities. Award or Honor #1Please provide a description of the award, the presenting organization, and the date it was awarded.Award or Honor #2Please provide a description of the award, the presenting organization, and the date it was awarded.Award or Honor #3Please provide a description of the award, the presenting organization, and the date it was awarded.NextESSAYSPlease provide a brief response to the following questions. What have you accomplished in these activities that are important to you and/or made a difference in the community or organization at large? *What do you hope to gain from participation in Leadership Hot Springs and what do you think you could give to this community as a past participant in this program? *What do you feel are the (2) most pressing problems facing the Hot Springs/Garland County area today? Explain why and give any recommendations that you may have for approaching and resolving these problems?NextTUITION AND FUNDINGName of Employer, Organization, or Individual Sponsoring Your Nomination:Will you need a partial scholarship to participate in this program? *YesNoIf yes, contact Leadership Hot Springs Executive Director at ___ for a scholarship form to be submitted with your application. Scholarship funds are limited. I UnderstandPARTICIPANT COMMITMENT AND PLEDGEPlease read the pledge in its entirety and confirm your willingness to abide by its commitments:1. I understand that attendance at all nine (9) monthly sessions for the full day is required. I also understand that attendance at the entire two-day (Friday and Saturday) weekend retreat in September is mandatory. Even though emergencies do arise, any participant missing more than two (2) class days will be dropped from the program and no portion of the tuition is refundable. (Missing more than one half (1/2) of a program day will be considered an absence for the entire day.) *AcceptDecline2. I understand that there may be other activities (program planning meetings, graduation banquet, etc.) in which all participants will be expected to participate. *AcceptDecline3. I understand that the tuition fee is $475.00 and that the full amount of tuition is due to Leadership Hot Springs no later than September 1. *AcceptDecline4. If selected, I will not use contents from the sessions or statements made therein for the purpose of news coverage or self-promotion. *AcceptDecline5. If selected, I will not use the name of Leadership Hot Springs in a political campaign to imply endorsement of Leadership Hot Springs. *AcceptDecline6. I release Leadership Hot Springs of any damages incurred to myself by participating in the programs. *AcceptDecline7. I understand that during each LHS monthly session, or other functions, I will be required to act in a dignified and respectful manner, particularly towards persons involved in the program. I also understand being in the LHS program may mean that I am exposed to people, ideas, or environments that are unfamiliar to me. I therefore agree to conduct myself in a professional and appropriate manner consistent with someone in a leadership role. I understand that my failure to do so may result in my removal from the Leadership Hot Springs program with no portion of the tuition refunded. *AcceptDecline8. I understand that my involvement in LHS is the beginning (or confirmation) of my active and ongoing participation in community organizational events and volunteer efforts. *AcceptDeclineSubmit