Name*

First Middle Initial Last

Cell Phone*

Email*

Home Address*

Street Address City State ZIP Code

Length of Residence in South Florida area*

Date of Birth*

Your Gender*

Female
Male

Persons with a disability?*

Yes
No

Ethnicity*

American Indian or Alaska Native
Asian
Black or African American
Caribbean American
Hispanic or Latino
White

Full name to be listed on name tag

Are you a previous applicant for the Leadership Broward program?*

Preferred Mailing Address*

Preferred Phone Number Listing in Members Only Directory*

EMPLOYMENT

Please list current employment and attach resume below (optional).

Current Employer*

Title*

Length of Time with Employer (Years/Months)*

Address of Employer*

Street Address City State ZIP Code

Business Phone*

Business Email*

In which sector do you work?*

For-profit
Government
Nonprofiit

Which best describes your type of business? (Your answer is for internal reporting purposes only and will not affect the strength of your application)*

Number of Employees

More than 250 employees
50 – 250 employees
Less than 50 employees

Previous Employment or Attach Resume Below

Upload Resume (Optional)

Drop files here or

Max. file size: 50 MB, Max. files: 3.

EDUCATION

School/University (if none, type N/A)*

School/University City

School/University State

Highest Degree Level Pursued

Associates
Bachelors
Masters
Doctorate

Major (and minor if applicable)

Graduated?

Dates of Education*

(Month/Year to Month/Year)

Other School/University Information

PROFESSIONAL AND OCCUPATIONAL ACTIVITIES

Organization Name*

Organization Dates of Participation*

(Month/Year to Month/Year)

Position Held*

Responsibilities

Organization Name 2

Organization Dates of Participation 2

(Month/Year to Month/Year)

Position Held

Responsibilities

Other Professional and Occupational Activies

VOLUNTARY COMMUNITY ACTIVITIES

List the key non-professional activities (charity, religious, school involvement, task forces or commissions) in which you have actively participated in the last 3 years.

Volunteer Organization*

Volunteer Dates of Participation

(Month/Year to Month/Year)

Position Held

Responsibilities

Volunteer Organization 2

Volunteer Dates of Participation 2

(Month/Year to Month/Year)

Position Held

Responsibilities

Other activities

In an average month, approximately how many hours do you spend on voluntary community activities?*

SPECIAL HONORS/AWARDS

List any professional or community honors or awards you have received

ESSAYS

Please answer in the space provided limiting each response to 100 words or less. No attachments please.

What do you consider to be your most significant professional or community contribution?*

What do you consider the most significant issue facing Broward County today?*

Why should you be selected for the Leadership Broward Class?*

REFERENCE FORMS

The applicant must include two completed Reference Forms from different people. This form is available on the application page of the LB website. If you do not have the completed forms available right now, you can submit your application today and email the forms by the 6/12/23 application deadline to apply@leadershipbroward.org.

Upload 2 References Forms

Drop files here or

Max. file size: 50 MB, Max. files: 3.

EMPLOYER CONSENT FORMS

Applicants must have the support of their employer. This form is available on the application page of the LB website. If you are self-employed or you are the CEO/ED/President, there is no need for the consent form. If you do not have the completed form available right now, you can submit your application today and email the form by the 6/12/23 application deadline to apply@leadershipbroward.org.

Signed Employer Consent Form

Drop files here or

Max. file size: 50 MB, Max. files: 2.

TUITION

If accepted into the Leadership Broward Class XLII, you and/or your employer will be invoiced for a tuition fee of $3,000. In order to hold your seat in the class, you and/or your employer must submit payment no later than 5:00 p.m., Friday, August 4, 2023.

Will your employer be responsible for your tuition?*

Will a sponsor be responsible for your tuition?*

Applicant Acknowledgment of Commitments

The dates of the local overnight retreat are Friday, September 29, 2023 - Saturday, September 30, 2023. Full participation at the retreat is mandatory, no exceptions.*

I agree to participate in the overnight retreat
I do not agree to participating in the overnight retreat

Tuition must be paid by Friday, August 4, 2023 and all parties previously listed in this application are responsible for payment to Leadership Broward Foundation, Inc.*

I agree.

Class members must participate in one full-day session per month from October 2023 to May 2024. Class members must also participate in a group community project. No class member may miss more than two program days and graduate. No exceptions.*

I understand and agree to fulfill the requirements listed above in order to graduate from the Leadership Broward Program.

LB will provide transportation during each program day. Class members are REQUIRED to utilize provided transportation during all program events. Personal vehicles or other forms of transport cannot be used during the program day. Class members are responsible for transportation to and from the pick up/drop off location.*

I understand and agree to the transportation terms listed above.

Photographs are taken throughout the program year. Participants must consent to the use of these photographs in any literature or videos related to Leadership Broward Foundation, Inc. for marketing and/or informational purposes.*

I agree.

Participants will be bound to the Leadership Broward Foundation Code of Conduct policy, as amended from time to time. Failure to adhere to this Code of Conduct may result in your removal from the Leadership Broward Program.*

I agree.

I understand the goals and commitment of the Leadership Broward program and the attendance requirements. If selected, I will fulfill all obligations outlined in this application and will see to payment of my tuition upon acceptance. I acknowledge that I have completed the application and that all information contained herein is true and correct. I hereby give Leadership Broward Foundation, Inc. the right to make inquiries regarding the information provided on this application form. Please write your full name below, this serves as an electronic signature.*

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LB APPLICATION CLASS XLII

EMPLOYMENT

EDUCATION

PROFESSIONAL AND OCCUPATIONAL ACTIVITIES

VOLUNTARY COMMUNITY ACTIVITIES

SPECIAL HONORS/AWARDS

ESSAYS

REFERENCE FORMS

EMPLOYER CONSENT FORMS

TUITION

Applicant Acknowledgment of Commitments

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