2018-2019 Leadership of Broken Arrow Application - GrowthZone

Contact Information

Title

First Name *

Last Name *

Suffix

Company Name *

Home Address

Address Line 1 *

Address Line 2

City *

Zip/Postal Code *

Home Phone Number *

Cell Phone Number *

Personal Email *

Work Address

Address Line 1 *

Address Line 2

City *

Zip/Postal Code *

Work Phone Number *

Work Fax *

Work Email *

Primary Email for LBA Communication *

*Communication will primarily be via email unless otherwise requested

Emergency Contact Information

Name (First & Last)

Phone Number *

Alternate Phone Number *

Have you previously applied to LBA? *

No Yes

If you checked yes, when?

How did you receive information on Leadership Broken Arrow? (Check all that apply) *

Chamber of Commerce Employer Friend Brochure LBA Alum Media Internet Other

If you checked other, please explain.

Program Fees

Program fees include materials, breakfast*, lunch* and administrative costs. The program fee for LBA 2018-2019 is $600. Applicant/business will be invoiced upon acceptance. Payment is due by August 10, 2018, (Tuition is non-refundable).

Program Fees will be paid: *

Personally By employer

Any special Dietary requirements, please explain:

Commitment

To graduate from LBA, you must attend a minimum of eight monthly sessions (90%) and the Kick-Off Session. We meet one day each month from September through May. Sessions will begin at 8:00 am and end by 4:30 pm. The Kick Off Session will be Thursday, August 23rd from 8:00a-4:30p and is MANDATORY! Plan to commit the entire day. Please be sure that your employer understands your commitment.

Please check any date that you are NOT available to attend LBA:

Session 1: Thurs, Sept 13, 2018 Session 2: Thurs, Oct 11, 2018 Session 3: Thurs, Nov 8, 2018 Session 4: Thurs, Dec 13, 2018 Session 5: Thurs, Jan 10, 2019 Session 6: Thurs, Feb 14, 2019 Session 7: Thurs, March 14, 2019 Session 8: Thurs, April 11, 2019 Session 9: Thurs, May 9, 2019

IMPORTANT: If a session needs to be cancelled due to weather we will try to reschedule to the following Thursday.

LBA does require volunteer hours outside of day sessions. These will be weekend and evening hours. (approx. 20 hours)

Are you willing and able to commit to the time required to fully participate in the LBA program this year? *

Yes No

LBA is a program designed to develop leaders within the Broken Arrow community. This involves attending local, non-profit board meetings. Are you willing to attend non-profit board meetings during the LBA program year? *

Yes No

Will you agree to continued service to the community through volunteer activities following this program year? *

Yes No

Business / Organization Agreement

Each candidate for the Leadership Broken Arrow program must have the support and commitment of his or her sponsoring business or organization. The signature of your supervisor/sponsor is necessary as an indication of support for the candidate’s participation in LBA. By signing below the supervisor agrees and supports the commitment required by all LBA participants (see commitment section above).

Supervisor / Sponsor Information

Title

First Name *

Last Name *

Suffix

Address Line 1 *

Address Line 2

City *

Zip/Postal Code *

If applicable, list the name and title of applicant’s immediate supervisor, if different from above.

Title

First Name

Last Name

Suffix

Contact person / address to send invoice:

Is PO required? *

Yes No

Is Chamber invoice required? *

Yes No

First Name *

Last Name *

Job Title *

Department *

Phone Number *

Address Line 1 *

Address Line 2

City *

Zip/Postal Code *

Employment / Professional Growth

Category of Employment: *

Banking Business / Industry Education Government Health Care Laborer Retired Other

If you selected other:

What do you feel is your highest leadership contribution to date in your business/professional career? *

Indicate your involvement in professional or business associations. *

Please include the name of the organization, the dates of membership and your leadership role.

Education

Provide information about your education. *

Please include the school name, city, the years attended, degree and major.

Cite extracurricular activities and special honors or awards for leadership activities:

Community Involvement / Leadership

Provide information about your community volunteer service. List your civic, social service, religious and/or other not-for-profit organizations in which you are or have been involved. (LBA will provide additional opportunities for involvement following program graduation.)

Please include the name of the organization, dates of membership and leadership role. *

Please describe a time when your community involvement had a positive impact. *

LBA Program Participation

Describe your motivation to participate in LBA and what you believe your future contribution to the community might be. *

What one thing in Broken Arrow would you build on or change? *

Describe one particular skill, knowledge, professional or technical expertise that could be helpful to LBA. *

Share one additional thing about yourself. If you are selected for LBA 2018-2019, this information may be shared. *

Applicant's Agrement

I hereby give LBA’s selection committee permission to verify any of the above information. LBA is an equal opportunity program. Race, gender, creed, national origin and political affiliation have no bearing on class selection. Applicant should reside or work in Broken Arrow, profess an interest in social and civic issues, be willing to listen to a broad range of opinions and participate in a cordial exchange of ideas. All individuals with an interest in the Broken Arrow community are welcome to apply. Class size is limited.

By signing this form you are giving consent for your name and/or picture to be released for LBA program promotion and community contact information.

If you DO NOT WANT your contact information published, please check this box.

Signature of applicant

First Name *

Last Name *

Date *

Format: MM/dd/yyyy

If you submitted your application prior to August 1, and have not heard from us by Aug. 5, please contact the Broken Arrow Chamber at 918-251-1518 to confirm receipt of your application. If application was submitted after Aug 1, you should hear back within 5 business days.