Application

Personal Contact Information

Prefix:

First Name:* Required

Middle Name:

Last Name:* Required

Preferred Name:* Required

Home Address:* Required

Home Address:

City:* Required

State:*

ZIP Code:* * Required Invalid Zip

Home Phone:* Required

Cell Phone:* Required

How did you hear about Lead Virginia?

Employment Information

Employer:* Required

Position or Title:* Required

Street Address:* Required

Suite:

City:* Required

State:*

ZIP Code:* Required Invalid Zip

Office Phone:* Required

Fax:

E-mail:* Required Invalid Email

Website:

Assistant’s name:

Assistant’s phone:

Assistant’s e-mail: Assistant info will be added to our database/list serve. Invalid Email

Briefly describe your company or organization, including the sector (public or private business, government, education, nonprofit or other profession) and type (i.e., banking, utility, marketing, military, higher education, law or community services).* Required

Demographic Information

I live in a(n):* Required

I work in a(n):* Required

Age:* Required

Years in Virginia:* Required

Family (spouse, children or significant): Required

Please describe your race or ethnic background:* Required

Community and Leadership Education

Have you completed a community leadership program or other leadership education or training? If so, please list the program(s) and year(s) completed and note your volunteer or leadership roles.

How are you currently serving in your community, your region or the Commonwealth? List organizations and positions held.

Lead Virginia’s primary objective is to build social capital. To accomplish this objective, our alumni consist of prominent leaders throughout the Commonwealth. Please explain your current leadership role(s) and the value that you will bring to the Lead Virginia alumni base.

Résumé

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Scholarship Assistance

Will scholarship assistance be necessary for you to participate in Lead Virginia?

If yes, how much assistance do you need?

Will lack of scholarship support preclude your participation in the class?
Please explain your reason for your request.

Issue Description

Describe your personal views on the following topic: What are the two most pressing issues or challenges facing Virginia today? Explain why and offer recommendations for approaching and solving these challenges. The suggested length of response is no more than one-half page.

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Statement of Commitment

Attendance at all programs sessions is strongly urged. Participants who miss more than two sessions will be asked to withdraw.

I understand Lead Virginia's attendance policy and will participate in all programs to the best of my ability.

Statement Of Agreement Required