2022 Leadership Robins Region Application

GENERAL INSTRUCTIONS

Please complete each section, limiting answers as specified. Application deadline is December 3, 2021, or when we reach class capacity of twenty-five (25), whichever comes first. Participants are selected on a first-come, first-serve basis once the application process has opened. A delay in submitting a completed application may result in being placed on the waitlist for the 2023 program.

STATEMENT OF ATTENDANCE & COMMITMENT

To graduate, attendance at all classes is expected. Roll is taken at the beginning and end of each morning and afternoon session; each of which counts as ½ day (.5 day). Class members must participate in the orientation class and the retreat. If an absence is necessary, a total 1.5 absences of the remaining 9 training-day sessions will be excused. A late arrival or early departure of 30 minutes or more will constitute a ½ day absence. If a participant has a total of more than three ½ day absences, the participant will be dropped from the class. No Exceptions. Illness, bereavement, military orders, employer requirements, etc. do not excuse any additional absences.

Do you commit to the attendance and participation guidelines above? *

Yes No

If employed, will your employer support your participation in the 2022 Leadership Robins Region Program as described above? *

Yes No

All Leadership Robins Region graduates agree to volunteer for a community service organization within one year of graduating from Leadership Robins Region. If selected as a participant, will you agree to fulfill your volunteer commitment? *

Yes No

If selected as a Leadership Robins Region participant, I will commit the necessary time and effort to complete the program. I understand that no more than 12 hours may be missed in order to complete the program and graduate.

Yes No

PERSONAL DATA

Please enter full legal name info in the next three boxes.(Some of our tours - for example, Robins AFB - require security pre-screening.)

Last Name *

First Name *

Middle Name *

Date of Birth *

Preferred Name (for Name Badge) *

Name Exactly as it should appear on Graduation Materials *

Office Phone Number *

Cell Phone Number *

Preferred Email Address *

Alternate/Secondary Email Address

Number of Years in Residence in Middle Georgia *

Business/Organization Mailing Address

Address Line 1 *

Address Line 2

City *

Zip/Postal Code *

Home Address

Address Line 1 *

Address Line 2

City *

Zip/Postal Code *

EMPLOYMENT INFO

Applicant's Current Job Title *

Current Employer *

Briefly describe your responsibilities in your employment. *

Current Supervisor's Name *

Current Supervisor's Title *

EDUCATION

High School or GED *

(Name of Educational Institution)

Post Secondary Education

(College, Technical College, Etc)

Advanced Degree(s)

List Special Recognition/Certificates/Achievements

ESSAY QUESTIONS

Please list, in order of importance to you, up to five civic, community, professional, social, or other organizational involvement, public offices held, and/or political activities. *

Please list civic/community organizations or causes you would like to become involved with in the future.

What do you consider your most significant professional achievement or civic contribution? *

What do you hope to gain from your participation in the Leadership Robins Region Program? *

What are the three most pressing issues facing the Robins Region today? And why? *

PERSONAL INFORMATION

During the course of the program, meals will be provided. Please indicate below any dietary restrictions we need to consider when planning meals & snacks. *

Polo Shirts - Ladies or Mens Style *

Ladies Mens

Polo Shirt Size *

Small Medium Last X-Large 2X-Large 3X-Large

Unisex T-Shirt Size *

Small Medium Last X-Large 2X-Large 3X-Large

Favorite Salty Snack (Type of Crackers, chips, nuts, etc) *

Favorite Sweet Snack (Type of Candy, cookies, etc) *

Favorite Daytime Beverage *

Favorite Evening Beverage *

TUITION

Tuition for Leadership Robins Region is $1,195 (members) and $1,995 (nonmembers) and is due by January 14, 2021. Tuition covers all program costs including the retreat, meals and graduation. Upon invoicing, payment may be made by check or credit card. If an applicant cancels within 10 business days prior to the retreat, one-half of the full tuition will be forfeited. If an applicant cancels after the retreat the entire tuition will be forfeited. *

I have read, understand and agree to the statement above.

GENERAL RELEASE FORM

In consideration of agreeing to participate in the Leadership Robins Region program, the Participant hereby releases the (i) Robins Regional Chamber (the "Chamber"), its agents, officers, servants and employees and (ii) any third parties providing facilities or work space access to the Participant while engaged in the Leadership Robins Region program, from any and all liability, claims, demands, actions and causes of action whatsoever arising out of or relating to any loss, damage or injury that may be sustained by the Participant or any property of the Participant while engaged in or under the control or supervision of the Chamber during the course of the Leadership Robins Region program. The Participant is duly aware of the risk and hazards inherent in participating in physical activities associated with trust and team building activities of Leadership Robins Region and is also aware of the potential risk and dangers inherent in workplaces and other locations the Participant may visit during the course of the Leadership Robins Region program. The Participant hereby voluntarily assumes all risk of loss, damage or injury that may be sustained by him or her or any property belonging to or in the possession of the Participant while engaged in the Leadership Robins Region program. Furthermore, to the extent that negligent or reckless actions of the Participant may cause damage to the workplace or facilities of third parties assisting with the Leadership Robins Region program, Participant agrees to indemnify and hold harmless Robins Regional Chamber from liability for such damage or injuries to third practices attributable to the negligent, reckless and/or intentional acts of the Participant. *

I have read, understand and agree to the statement above.

PHOTOGRAPH AND MEDIA RELEASE

I understand that photographs and video may be taken of the participants during the course of the Leadership Robins Region program. I consent to such photographing and videotaping for the use by Leadership Robins Region and the Chamber, without compensation, of my name, image, likeness, whether in film, photographs or any other media for the promotion by the Chamber of Leadership Robins Region and other activities of the Chamber. *

I have read, understand and agree to the statement above.

Robins Regional Chamber

2022 Leadership Robins Region Application

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