Complete Form

KLA Class Application

Kosciusko Leadership Academy group photo of five adults holding a United Way Good Night box.

Personal Data

Name*

First Last

Preferred Name for Name Tag

Home Address*

Street Address Address Line 2 City State ZIP Code

Number of Years*

Living and/or Working in Kosciusko County

Please enter a number from 0 to 100.

Home Phone Number*

Personal Email Address*

Employment

Present Employer*

Year of Hire*

Business Address*

Street Address Address Line 2 City State ZIP Code

Business Phone Number*

Business Email Address*

Title / Responsibility*

Name of Supervisor / Sponsor*

Education History

Name of School*

Highest Degree Earned*

Degree / Major*

Dates Attended*

If more to list, please use this box.

Community Involvement

List Involvement*

Please list professional, religious, community, athletic, social, or other organizations of which you are a member. Please note any leadership positions held.

General Information

What are your reasons for desiring to participate in the Kosciusko Leadership Program?*

Recommendations

Personal References. Please list two (2) persons other than your sponsor who are knowledgeable about your leadership performance and potential.

Reference 1 - Name*

First Last

Reference 1 - Phone*

Reference 1 - Organization*

Reference 1 - Title*

Reference 2 - Name*

First Last

Reference 2 - Phone*

Reference 2 - Organization*

Reference 2 - Title*

Finances

If selected, payment of tuition will be made by each participant or financial sponsor. Tuition is due and payable by the first day of class.

How will tuition be paid?*

Commitment

By entering my name below I am agreeing that if selected as a participant, I am willing to attend all the programs, will complete a white paper and complete other assignments required by the program. I understand that if I fail to meet any part of this obligation, I may be asked to either withdraw from the program or make up missed sections the following year.

Enter Name*

First Last

Email Address to Receive Copy of Submission*

Name

This field is for validation purposes and should be left unchanged.

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Personal Data

Employment

Education History

Community Involvement

General Information

Recommendations

Finances

Commitment

Interested in Going Through the Kosciusko Leadership Academy?