.application_test Western Connecticut Leadership Application Please create a password for your application when prompted below. If you do not complete your application in one sitting, you may log in and return to edit the application before submitting a final version. Your username and password will be emailed to the email address you enter. If accepted in the program, your username and password will allow you to review and edit your directory profile information. First Name * Last Name * Nickname or Preferred Name Password * Please enter a password (up to 10 characters). Your user name and password will be emailed to you. Gender * Female Male OtherOther Upload Your Photo Drop a file here or click to upload Choose File Maximum upload size: 268.44MB Contact Information Local Street Address * Local City * Local State * Connecticut Local Zip Code * Local Phone Number * Cell Phone Number Email Address * Is this your primary mailing address? * Yes No Alternate Contact Information If you have an alternate address where you would like to receive information, please indicate below. I have an alternate address Alternate Street Address Alternate City Alternate State Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware 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 Alternate Zip Code Alternate Phone Number Is this your primary mailing address? * Yes No About You Which statement best describes you? * I live in Connecticut full time (more than 10 months per year) I live in Connecticut 1-6 months per year I live in Connecticut 7-10 months per year I am a weekender How many years have you lived in Western CT? * What is your current employment status? * Retired Semi-retired Employed Why are you interested in participating in WCL? * Please share what motivated you to apply and what you hope to get out of the program. Education History Please let us know about any degrees you have attained. College or University Field of Study Degree AA AS BA BS JD MA MBA MD MPA MS MSW PhD Other Other Degree College or University Field of Study Degree AA AS BA BS JD MA MBA MD MPA MS MSW PhD Other Other Degree College or University Field of Study Degree AA AS BA BS JD MA MBA MD MPA MS MSW PhD Other Other Degree Career History Please share the three most recent positions you have held. Company or Organization (most recent) Position Held Start/End Year Company or Organization Position Held Start/End Year Company or Organization Position Held Start/End Year (Optional) Other significant work experience Current and Past Civic/Community Involvement Please share three to five recent community engagement activities, including the company/organization's name, your responsibilities, and your year(s) of service. Please list the most local work first. Other relevant information If someone referred you to the program, please provide name and contact information below. Name Phone Number Email Address How did you first hear about Western Connecticut Leadership (WCL)? * Friend, family member or an alumnus of WCL Attendance at a WCL information session News article Social media (Facebook, Twitter or other) Website Email or newsletter from Connecticut Community Foundation Connecticut Community Foundation event Other (please describe):Other (please describe): Cost of the program is $650. Limited need-based scholarships are available to aid with program tuition. Please indicate if you would like to be considered for a scholarship. * Yes No We do not want cost to be a barrier for participation. You will be contacted with more information, if you are interested in aid. Application Submission Please note that WCL is an educational program, not a professional training program. Is this your final submission? If so, say YES and a copy of your application will be emailed to you. If NO, you will need to log in again in order to edit or finish your application. Your application will not be COMPLETE until you indicate that it is your final submission. * No Yes Δ
