Orange Community Services Department
Senior Leadership Program
Confidential Participant Application
Mr./Ms./Mrs./Other _______ Date of Birth _____________
Name
_______________________________________________________
Home Address
_______________________________________________
Town of
Home Phone
__________________________________________________
E-mail address
________________________________________________
Briefly describe your
leadership experience.
What do you think are our
community’s greatest assets?
What do you think are our
community’s greatest challenges?
COMMUNITY NEEDS
In your judgment, what are
the three most pressing problems facing the town of
What speakers would you like
to have included in the Senior Leadership Program?
GENERAL
What do you hope to gain from
the Senior Leadership experiences? Skills/Knowledge?
What are your reasons for
wanting to participate in the Senior Leadership Program?
Please list any volunteer
activities you are participating in AT THIS TIME.
SIGNATURE
I understand there is a
required tuition of $100 if I am accepted into the Senior Leadership Program.
Applicant
____________________________________ Date ____________
Sponsor (if applicable)
__________________________________
Mail application and two
letters of reference to:
Orange Community Services
Department,
Attention:
Application Deadline: August 29, 2011