ChamberMaster Template

2018-2019 Leadership of Broken Arrow Application

Contact Information
Home Address
Work Address
*Communication will primarily be via email unless otherwise requested
Emergency Contact Information
Have you previously applied to LBA? *
How did you receive information on Leadership Broken Arrow? (Check all that apply) *
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: *
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:
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? *
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? *
Will you agree to continued service to the community through volunteer activities following this program year? *
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
If applicable, list the name and title of applicant’s immediate supervisor, if different from above.
Contact person / address to send invoice:
Is PO required? *
Is Chamber invoice required? *
Employment / Professional Growth
Category of Employment: *
Please include the name of the organization, the dates of membership and your leadership role.
Please include the school name, city, the years attended, degree and major.
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.)
LBA Program Participation
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.
Signature of applicant
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.