Application Form

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Application Form

Please type or print clearly. Attach additional materials as required.

APPLICANT'S INFORMATION:

Last Name:		First Name:
Home Address:
City:		Postal Code:
Home Phone		Fax
E-mail

Work Place
Work Address
City		Postal Code
Work Phone		Fax
E-mail
Title/Position

Where did you hear about Leadership Regina?

Alumni		Employer
Board		Leadership Regina Event
Community Organization
Media (please specify)
Other (please specify)

Please respond to the following questions
(Responses must be limited to the space provided).

1. Describe one or two experiences in your personal journey where you demonstrated leadership initiative. What actions did you undertake? What did you learn from these experiences?

2. Identify three challenges facing Regina, and selecting one, outline how you would like to
make a difference.

3. How would you define community leadership?

4. Tell us about yourself and why you would like to be selected for Leadership Regina.

5. One of the primary objectives of Leadership Regina is to create networks of individuals representative of our community's various sectors. In order to assist us in our selection of candidates, please identify below the sector of the community from which you are applying.

	Business		Faith
	Not-for-profit/charitable		Community association
	Government (municipal, provincial, federal)		Community
	Labour		Education
	Other: Please specify

Be sure to include the following in your application package:

	Application Form
	Resume (including professional, education, and community-based experience)
	Commitment Form
	Letters of Endorsement (2)

Submit the completed application form and submit it electronically or mail to the following address by MAY 31, 2006 to:

LEADERSHIP REGINA
#204 - 2314 – 11th Avenue
Regina, SK S4P 0K1
Fax: 306-522-7199
www.leadershipregina.com

Commitment Form

The Program

Full attendance in the entire program is essential. It is vital that both you and your employer understand and honour these commitments. It is anticipated that at least 13 days of your time will be required to complete the 10-month Leadership Regina program. If your employer is not sponsoring your involvement, it is important that you secure their support to ensure that this course is a priority for your time.

You will be required to attend the Opening Retreat as well as the Leadership Focus days which will generally be scheduled from 8:30 am to 5 pm on the assigned dates. Following completion of the program, you will be assisted in locating an opportunity for continued community involvement that will allow you to apply the skills learned.

Personal Commitment

If selected, I will devote the time and resources necessary to complete the Leadership Regina program. I understand that should I be absent for any reason from any part of the Opening Retreat, or from more than two all-day Leadership Focus days, I may be required to withdraw from the program and my program fee will not be refunded or transferred.

By submitting this form, I confirm my understanding of the goals and time commitments of LEADERSHIP REGINA.

Additionally, I confirm that my employer or supervisor also understands and agrees to the time commitment.


Applicant	Date

Employer/Sponsor Commitment (if applicable)

This applicant has the approval of this organization and the applicant has our full support, if accepted, to devote the time required to participate in the program.

If this applicant is accepted, I agree to pay of the Leadership Regina fee for the above participant. I understand the tuition is non-refundable and non-transferable.

By submitting this form, I confirm my understanding of the goals and time commitments of LEADERSHIP REGINA.

Applicant's Name
Employer/Sponsor Name	Position
Date

Financial Commitment

The Leadership Regina program tuition is $1000 for the full ten-month program.
This fee covers food and lodging for all scheduled events.

Payment in full is due no later than SEPTEMBER 10, 2006.

All tuition payments are non-refundable and non-transferable.

It is suggested that participants personally pay a portion of the tuition fee, that amount to be self-determined based on their best ability. Applicants may request bursary support for a portion of the tuition. Request for bursaries has no effect on the selection of participants into the program.

Please complete the following and obtain signatures where required.

If selected:

	I agree to pay
	My employer/sponsor agrees to pay
	I am applying for bursary support in the amount of
	Total tuition	$ 1000.00

If you are applying for bursary support please explain the reason for your request.

Letter of Endorsement [ 1 ]

Please print and forward to your references OR invite them to submit their remarks electronically.

Name of individual making recommendation:

Briefly describe for how long have you known the applicant and the nature of your relationship.

Based on your knowledge of the applicant please give examples of how he/she has demonstrated leadership qualities in their professional and or community involvement.

Describe why you believe the applicant is an excellent candidate for Leadership Regina?

By submitting this form, I confirm my understanding of the goals and time commitments of LEADERSHIP REGINA.

Applicant's Name
Endorser	Date

Letter of Endorsement [ 2 ]

Name of individual making recommendation

Briefly describe for how long have you known the applicant and the nature of your relationship.

Based on your knowledge of the applicant please give examples of how he/she has
demonstrated leadership qualities in their professional and or community involvement.

Describe why you believe the applicant is an excellent candidate for Leadership Regina?

By submitting this form, I confirm my understanding of the goals and time commitments of LEADERSHIP REGINA.

Applicant's Name
Endorser	Date

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