LeadershipClass Application

Application Fee: First Name: Preferred Name: Last Name: What is your preferred pronoun? he/him/his she/her/hers they/them other Company: Title: Category Architecture - Engineering Art - Entertainment Banking - Insurance Chamber of Commerce Community Organization Community Volunteer Construction Consulting Defense Education Energy Faith Finance - Accounting Food - Beverage Foundations Government Health Care Hotels - Travel Investments Law Manufacturing Media - Communication Non-Profit PR - Advertising Real Estate - Development Retired Retail Social Services Transportation Utilities Other If you've chosen "Other", list your Industry here: What is your LinkedIn profile URL? Direct Supervisor: Title: Email: Work Phone: Address: Address Line 2 City: State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico U.S. Minor Outlying Islands Virgin Islands Armed Forces Americas Armed Forces Europe, the Middle East, an Armed Forces Pacific Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Territory Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory Zip Code: - Zip Suffix Preferred Mailing Address: Work Address Home Address Email: Email 2: Preferred Contact Method: Work Email Personal Email Phone: Phone 2: Preferred Phone Number: Work Personal How many years have you resided in Fort Worth or surrounding areas 0-5 5-10 10+ Which Fort Worth city council district do you reside? Go to https://myreps.datamade.us/ Which Fort Worth Fort Worth city council district are you employed in? Go to https://myreps.datamade.us/ What County Commissioner district do you live in? Go to https://myreps.datamade.us/ Date of Birth Gender Ethnicity American Indian/Alaskian Native Asian Black/African-American Hispanic Multiracial Native Hawaiian/Pacific Islander White Other Spouse/Partner Name To which class are you applying? LeadershipClass 2023 LeadingEdge 2023 Have you previously applied to Leadership Fort Worth? Yes No Describe your position and responsibilities at your current employer. List key community, civic, religious boards, task forces or commissions in which you have been an active participant and give the approximate number of hours you volunteer with each organization per month. (If you moved to Fort Worth recently, please list activities you were involved with in your previous community.) How do you define leadership? For example who influences you as a leader? What do you consider to be the two most significant challenges facing Fort Worth today? Choose one challenge and discuss how you hope your Leadership Fort Worth experience will contribute to its solution. How do you see yourself involved as a community leader in the future? What do you hope to gain from participation in Leadership Fort Worth that will help you achieve your vision? Working across community is important to LFW, can you describe how you collaborate across different communities to build a more inclusive Fort Worth? Are you requesting a tuition waiver? Yes No Tuition Waiver Amount Request: Tuition wavier amount requested: $ Should you be selected, we need to know if you have any dietary restrictions as meals are served during program days. Please be as specific as possible or type NONE if you have no restrictions. Please indicate if you require any additonal mobility, ability or learning accommodations for the duration of the program I agree to the above expectations. I have reviewed the program calendar and agree to the attendance requirements. Additionally, I hereby give Leadership Fort Worth the right to make inquiries regarding the information provided on this application. Check all that apply: Reference #1 Name Reference #1 Company & Title Reference #1 Email Reference #1 Phone