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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.

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Name *

First

Last

Preferred Title

Mr.
Ms.
Mrs.
Miss
Dr.
Other

Home Address

Address Line 1

Address Line 2

City

State

Zip Code

Primary Phone *

Your preferred contact number.

Mobile Phone *

A secondary number where we can reach you.

Email *

Spouse's Name

First

Last

If applicable.

Reference #1 *

First

Last

Reference #1 Phone *

Relationship to #1 *

Reference #2 *

First

Last

Reference #2 Phone *

Relationship to #2 *

EDUCATION

Begin with high school; then list college(s); business, trade schools, and/or other specialized training.

High School Name *

Address Line 1

Address Line 2

City

State

Zip Code

Start Date

End Date

School #2 *

College or university; accreditation program, trade schools, and/or other specialized training.

Address Line 1

Address Line 2

City

State

Zip Code

Start Date

End Date

Degree or Certification Earned

Major/Minor or Specialty/Focus

School #3 Name

College or university; accreditation program, trade schools, and/or other specialized training.

School #3 Address

Address Line 1

Address Line 2

City

State

Zip Code

Start Date

End Date

Degree or Certification Earned

Major/Minor or Specialty/Focus

Special Awards or Honors for Academic Performance

EMPLOYMENT

Please begin with your current employer, then list workplaces in reverse chronological order.

Current Employer *

Date Employment Began

Current Title or Responsibility

Name of Previous Employer #1

Start Date (Previous Employer #1)

End Date (Previous Employer #1)

Title & Responsibilities (Previous Employer #1)

Name of Previous Employer #2

Start Date (Previous Employer #2)

End Date (Previous Employer #2)

Title & Responsibilities (Previous Employer #2)

COMMUNITY ACTIVITIES

List key community, civic, professional, busines, religious, social, or other organizations you have been involved in within the past five (5) years.

Organization #1

Please provide the organization name, dates of membership, and position(s) held.

Organization #2

Please provide the organization name, dates of membership, and position(s) held.

Organization #3

Please provide the organization name, dates of membership, and position(s) held.

Organization #4

Please provide the organization name, dates of membership, and position(s) held.

Organization #5

Please provide the organization name, dates of membership, and position(s) held.

AWARDS & HONORS

Please list any special awards or honors you've received for education or leadership activities.

Award or Honor #1

Please provide a description of the award, the presenting organization, and the date it was awarded.

Award or Honor #2

Please provide a description of the award, the presenting organization, and the date it was awarded.

Award or Honor #3

Please provide a description of the award, the presenting organization, and the date it was awarded.

ESSAYS

Please 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?

TUITION AND FUNDING

Name of Employer, Organization, or Individual Sponsoring Your Nomination:

Will you need a partial scholarship to participate in this program? *

Yes
No

If yes, contact Leadership Hot Springs Executive Director at ___ for a scholarship form to be submitted with your application. Scholarship funds are limited.

I Understand

PARTICIPANT COMMITMENT AND PLEDGE

Please 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.) *

Accept
Decline

2. I understand that there may be other activities (program planning meetings, graduation banquet, etc.) in which all participants will be expected to participate. *

Accept
Decline

3. 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. *

Accept
Decline

4. If selected, I will not use contents from the sessions or statements made therein for the purpose of news coverage or self-promotion. *

Accept
Decline

5. If selected, I will not use the name of Leadership Hot Springs in a political campaign to imply endorsement of Leadership Hot Springs. *

Accept
Decline

6. I release Leadership Hot Springs of any damages incurred to myself by participating in the programs. *

Accept
Decline

7. 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. *

Accept
Decline

8. 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. *

Accept
Decline

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Leadership Hot Springs
Adults
Youth
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Email: contact [at] leadershiphs.org

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