Application for Admission to: Leadership for a Sustainable Future Class of 2015 - 2016 Early Bird Deadline: 5:00 pm Wednesday, April 22, 2015 (5% Tuition Discount) Final Application Deadline: 5:00 pm Monday, May 11, 2015 Please respond to each question in the space provided. If additional space is needed attachments may be used .Note: You must have Adobe Reader 8 or above installed on your computer to fill out this application. To download the free Adobe Reader Click Here I. APPLICANT INFORMATION Last Name:  Male  Female First Name: Home Address: City: ___________________ Zip: ____________ Home Phone: Work Phone: E-mail Address: Age (optional): What race(s) or ethnicities do you most strongly identify with? (optional) White or Caucasian Hispanic or Latino Black or African American Native American Asian Indian Chinese Japanese Korean Vietnamese Filipino Other Asian Native Hawaiian Samoan Other Pacific Islander Other, please specify (The above categories adopted from the 2010 US Census) How did you hear about the course? II. EMPLOYMENT AND WORK-RELATED ACTIVITIES A. Present Employer: Your Title: Type of Business/Agency: Date Began: Work Address: Briefly describe your responsibilities: B. Previous Employment (begin with the most recent): Employer/ Agency III. Title or Responsibility Length of Employment EDUCATION AND TRAINING Name & City of Institution Date & Degree or Certificate 1 Major or Emphasis of Coursework IV. COMMUNITY SERVICE: Non-profits, neighborhood groups, service organizations, etc Organization What did you do? When? How many hours per month do you currently contribute to community activities? V. PUBLIC SERVICE: Elected or appointed office, boards and commissions, etc Jurisdiction Role or Position When? VI. ADDITIONAL INFORMATION If you require more space for your answers, attachments may be used. A. Why do you want to participate in the Leadership for a Sustainable Future Program? B. What kind of leader are you and how do you think this program will strengthen your leadership skills? 2 C. What do you think are the most important issues in each of the three pillars of sustainability in our community: the environment, the economy and social equity? Why are these particular concerns important to you? D. Which of your personal, professional, or community achievements has made the greatest impact on your life? How did this achievement improve your leadership capabilities? Please return the entire application, including page 4, as an email attachment to: [email protected] no later than 5:00 pm Monday, May 11, 2015. Applicants will be notified of their status by June 26, 2015. All information will be kept confidential. 3 Program Tuition – Class of 2015/2016 P lease com plete this form and send in w ith your application. If you are accepted to the program a final signed version m ust be submitted w ith your participant agreement. Tuition for Leadership for a Sustainable Future is based on a sliding scale from $1000.00 - $2,500.00 to accommodate varying household income levels and is tagged to the median household income level in Sonoma County. The Leadership Institute believes this course should reflect the communities in which we live and work, and we are committed to making the program widely available. • If you submit your application on or before April 22, 2015, you will receive a 5% tuition reduction. The following sliding scale chart is used to determine fees based on your annual household income. If your annual household income is Program Fee $80,000 and up $2,500 $60,000 - $79,999 $1,750 $59,999 and below $1,000 Organizational Sponsorship* $5,000.00 PAYMENT PLANS: Please select one of the following payment plans. Payment Plan A _______ Payment Plan B _______ Total Tuition Due Plan A Plan B $5,000 $5,000 $2,500 $2,500 $625 $625 $625 $625 $1,750 $1,750 $437.50 $437.50 $437.50 $437.50 $1,000 $1,000 $250 $250 $250 $250 Due On: July 31, 2015 July 31, 2015 August 31, 2015 September 30, 2015 October 31, 2015 TOTAL TUITION DUE Program fee from chart above: $_______________ Less 5% Early Bird discount if your application is received by April 22: $_______________ TOTAL Program Fee: $_______________ I will make payments by: Check _______ Credit Card through PayPal _______ N OTE: If w e have not received your paym ent in full by October 31, 2015, you w ill be asked to w ithdraw from the program. *Please see our website for details about our Organizational Sponsorship program. 4