2022-2023 Vision 2040 Leadership Application Name(Required) First Last Address(Required) Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell Phone(Required)Work PhonePersonal Email(Required) Work Email(Required) Employer/Business(Required) Supervisor Name(Required) Supervisor Email(Required) Gender Female Male Prefer not to say Other Age Under 40 40 and Over Prefer not to say Race/Ethnicity (select all that apply) African American/Black African Caucasian Hispanic/Latino Pacific Islander Native American Prefer not to say Other Is there anything that would prevent you from participating in all scheduled sessions?(Required) Yes No Please explain anything that would prevent you from participating in all scheduled sessions? How did you learn about Vision 2040 Leadership? Presentation Lunch & Learn Social Media Newsletter Newspaper/Radio Mailing Personal Invitation Other Please list any previous leadership programs you have participated in.(Required)What do you want to gain from your Vision 2040 Leadership journey? Include personal, professional and community expectations.(Required)How will you use the leadership training you receive to benefit your community?(Required)Please share any other information you would like the selection committee to know about you or your community involvement.Please check each that applies (*) are required:(Required) I understand that completion of this application does not guarantee placement in the Vision 2040 Leadership Class of 2023. I understand that tuition in the amount of $800 is due upon acceptance to the Vision 2040 Leadership Program and must be received prior to the beginning of the first session. I have read the information on Vision 2040 Leadership included in this application and understand the expectation for participation in the program. I understand that I must be able to attend all sessions; these typically occur from 8:30-4 on the first Thursday of the month from September through April. I also understand that if I am not able to attend 2 or more sessions, I will not graduate the program. The registration fee would be a financial hardship and create a barrier for me to participate.(Required) Yes No Scholarship ApplicationProgram Fee: $800.00 I would like to be considered for general scholarship funds. Without these scholarship funds, I would not be able to attend Vision 2040 Leadership class. Please provide assistance in the amount of $100 to $600. Please list amount requested below.(Required) Personal Reason for request:(Required)I am from a small business of 20 or less employees.(Required) Yes No Please check your agreement with these statements:(Required) Send a thank you note to scholarship fund. Attend all sessions. Write an impact statement upon completion of course. Grant release of my final impact statement and permission to use photos for marketing purposes. EmailThis field is for validation purposes and should be left unchanged.