2012 Leadership Kansas Application

All Applications Must Be Submitted By January 31, 2012

Technical NOTE: It is highly recommended you familiarize yourself with this Application and have your answers prepared prior to filling out and submitting. (Allowing this page to be open too long increases the possibility of connectivity loss and the inability to correctly submit data.) Each field of this form must be complete before your Application can be submitted and questions 1-8 will have a character count preceding the question; the use of a word processor and its ability to spell-check and calculate characters, is also recommended.

First Name

Middle Initial

Last Name

Spouse's Full Name

Home Address

City

State

Zip Code

Home Phone

Cell Phone

Email Address

Place of Employment

Job Title

Business Address

City

State

Zip Code

Business Phone

Immediate Supervisor

Supervisor's Title

Date Birth*

Race/Ethnicity*

* This information is used to help achieve a group representative of the entire state.

Who Nominated You (if known):

Have You Previously Submitted A Leadership Kansas Application?:

If Yes, What Year/s? If No enter "none":

Attendance Policy

It is understood that the applicant is aware of the dates and time commitment for each Session, and if accepted into the Program, agrees to attend ALL Sessions. Excused absences due to extenuating circumstances will be taken into consideration by the Board of Trustees.

Class Orientation	April 20-21, 2012	Lawrence (noon-noon)
Session #1	May 30-June 1, 2012	Garden City
Session #2	June 27-29, 2012	Hutchinson/Wichita
Session #3	July 25-27, 2012	Junction City/Manhattan
Session #4	August 22-24, 2012	KC Metro
Session #5	September 26-28, 2012	Hays
Session #6	October 24-26, 2012	Topeka (Evening Graduation)

All Sessions Will start Wednesday at 5 p.m. and end at Noon Friday. *(Exceptions are sessions #2 and #4 which will end at 3pm on Friday.

I will attend all Sessions if selected:

Attendance Waiver

I would ask to be considered for the 2012 Program but I am currently aware of a specific conflict that will/may prevent me from attending part/all of one of the scheduled 2012 Sessions. The details are as follows:

USE SPACE PROVIDED to address the following sections with as much information as you have available, while refraining from listing an award or honor in more than one section. Only a duplicate of this form will be sent to the Selection Committee. Again, you are limited to only the space provided for each question. Each question will have a character count below the question indicating how many characters are remaining to answer that question.

1. Please state present job description and work responsibilities:
(750 Characters)

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2. Please list all work experience. List job and brief job description:

3. Please list all formal education as well as any educational accomplishments within the field of work. Include degrees awarded and/or professional institutes and training programs attended:

4. Please list all (past and present) community, social, business, and professional affiliations. Indicate the scope of your responsibilities:
(1,020 Characters)

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5. Please list all awards or special recognition that you have received through your involvement in professional and/or community activities:
(570 Characters)

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6. What are your future leadership goals?:
(930 Characters)

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7. What do you see as the Future of Kansas?:
(1,560 Characters)

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8. Please list your personal interests or hobbies outside of your profession:
(360 Characters)

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9. Name & Contact Information of Person Submitting Your Letter of Recommendation:

Gary Sherrer Financial Assistance Endowment

In an effort to ensure that the benefits of Leadership Kansas are available to all Kansans, irrespective of their ability to pay, the Kansas Chamber and the Leadership Kansas Board of Trustees are pleased to provide Financial assistance to those in need. Through the generous contributions of Leadership Kansas Alumni, grants of up to $625 are available upon request from the Gary Sherrer Financial Assistance Endowment. A formal letter requesting the financial assistance, an explanation of need, and the amount requested should be mailed to Leadership Kansas. All requests are confidential and shall have no bearing on the selection process. Leadership Kansas tuition is $1,500 for 2012.

10. I am interested in receiving LK Financial assistance:

If Yes, enter the amount requested. If No, enter "none":

Application Fee

There is a $50.00 non-refundable Application Fee. You may make payment by mail or electronically at: Leadership Kansas Application Fee ONLY after you have completed and submitted your Application.

My Application Fee Has Been Mailed or Paid Electronically:

Application Fee Waiver Policy

All applicants who submitted an Application for consideration for the year immediately preceding this Program Year, and paid an Application Fee, will not be required to submit an Application Fee with their current Application.

I Paid An Application Fee In 2011 And Am Exempt From Submitting One With My 2012 Application:

IMPORTANT: Your Application file shall be considered “incomplete” by the Selection Committee until the application fee and letter of recommendation are received.

Please only click Submit once. If you have any questions regarding your application, please contact Dan Murray or Lauren Bohning at (785) 290-0017.

Leadership Kansas is an affiliate of The Kansas Chamber

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Leadership Kansas
900 S. Kansas Avenue
Topeka KS 66612
(785) 290-0017
E-mail: lkstaff@leadershipkansas.org

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