Applicant Name:

Applicant Address:

City: State: Zip:

Home Phone:

Cell/Work Phone:

Email Address:

Name of Your Neighborhood:

Name of Organization and your title [if applicable] :

Please check the box that best fits you:
Gender: Male Female
County of Residency: Hillsborough Pinellas

Primary Area(s) of Interest:

Affordable Housing
Senior Issues
Faith-Based
PTA/Schools
Health and Nutrition
Community Clean-Up
Economic/Business Development
Neighborhood Associations
Youth/Civic Engagement
Crime/Community Safety
Parks/Beautification
Other (Please List - Separated by Commas)

Briefly describe your involvement in the community:

Using your personal and professional experience, please answer the following questions:

1.How did you come to be known as a leader?

2. What skills does it take to be an effective leader?

3. What skills do you need to work on to be a better leader?

4. What suggestions do you have for us as we work to help leaders develop?

Commitment Clause
I understand that this program has limited seating and my selection is based on my level of commitment to the program. The curriculum consists of five Saturday sessions and I agree to complete at least four of the five sessions to receive the program Certificate of Completion, and to be eligible for other benefits associated with this program.

By clicking below, I agree that I am making the commitment to complete the Tampa Bay Community Leadership Development Program.