Middle Georgia Regional Leadership Champions Program. A Program of the Middle Georgia Regional Commission APPLICATION DEADLINE: JANUARY 24, 2018

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1 Middle Georgia Regional Leadership Champions A Program of the Middle Georgia Regional Commission APPLICATION DEADLINE: JANUARY 24, 2018 The Middle Georgia Regional Leadership Champions (MGRLC) program is a collaborative effort of the Middle Georgia Regional Commission, in partnership with the University of Georgia s J.W. Fanning Institute for Leadership Development and the Carl Vinson Institute of Government. The program is designed to bring together a diverse group of stakeholders from across Middle Georgia to develop enhanced leadership capacity within the region and actively shape the future vision of a thriving Middle Georgia. Designed to create awareness and advocacy around the importance of regionalism, the MGRLC program offers an advanced, one-of-a-kind leadership development opportunity which will facilitate both individual and regional competencies around strategic goals and priorities. Originally started in 2015, the MGRLC program is now welcoming its third class of community leaders. Participants will play a vital part in establishing a foundation for the region to collectively respond to and prepare for future growth needs and challenges. SELECTION PROCESS A selection committee has been appointed to review all applications and make selections for the 2018 MGRLC class. Applications will be received by the Middle Georgia Regional Commission and provided to a selection committee for their review, consideration, and deliberation. APPLICATION SUBMISSION REQUIREMENTS Please return the completed application and the program commitment form (page 9) by Wednesday, January 24, 2018, via mail, hand-delivery or to: Mr. Greg Boike Director of Public Administration Middle Georgia Regional Commission 175 Emery Highway, Suite C Macon, GA gboike@mg-rc.org NOTIFICATION The 2018 Middle Georgia Regional Leadership Champions class will be announced via and on the MGRC website by February 1, Middle Georgia Regional Leadership Champions Program 1 P a g e

2 PROGRAM REQUIREMENTS The Middle Georgia Regional Leadership Champions Program consists of seven informative and interactive sessions designed to educate participants about key community issues facing Middle Georgia while imparting relevant leadership skills through adaptive and reflective learning experiences. Beginning in March 2018, the program will be held once a month in different locations throughout Middle Georgia. The overnight retreat will be held at the Retreat at Lake Blackshear, Cordele, Georgia. ATTENDANCE Participants must attend ALL of the scheduled sessions in order to successfully complete Middle Georgia Regional Leadership Champions Program, including the Orientation/Overnight Retreat. Additional hours may be required outside of scheduled sessions to meet program requirements. DATES Session Date(s)* Time Orientation/Overnight Retreat Day One March 16-17, pm (3/16) 8 am-3 pm (3/17) Session #1 April 19, am-4 pm Session #2 May 17, am-4 pm Session #3 June 21, am-4 pm Session #4 July 19, am-4 pm Session #5 August 16, am-4 pm Commission and Charge September 21, am-4 pm TUITION If selected, the tuition for the program is $200.00, payable by February 23. The tuition includes meals and overnight accommodations for all sessions. ELIGIBILITY REQUIREMENT To be eligible, applicants must be at least 21 years of age and reside in one of the following Middle Georgia counties: Baldwin, Crawford, Houston, Jones, Macon-Bibb, Monroe, Peach, Putnam, Pulaski, Twiggs or Wilkinson. 2 P a g e

3 Application for the Middle Georgia Regional Leadership Champions Program A Program of the Middle Georgia Regional Commission APPLICATION DEADLINE: January 24, 2018 All information provided during the application process will be reviewed for selection purposes only and will remain confidential. Please provide sufficient information for the MGRLC Selection Committee to determine your eligibility based on your skills and commitment to community and regional involvement. To ensure that those selected reflect the diversity of the region, you are asked to specify your gender, race, and/or ethnicity. All questions are optional. 1. BASIC INFORMATION LAST NAME FIRST NAME MIDDLE INITIAL NICKNAME / CALLED COUNTY OF RESIDENCE COUNTY OF EMPLOYMENT HOME ADDRESS CITY ZIP HOME PHONE CELL PHONE AGE GENDER RACE/ETHNICITY HOW LONG HAVE YOU LIVED/WORKED IN MIDDLE GEORGIA? SHIRT SIZE (S, M, L, XL, XXL) DIETARY CONSIDERATIONS FOR MEAL PLANNING PURPOSES 2. EMPLOYMENT INFORMATION NAME OF EMPLOYER SUPERVISOR S NAME (IF APPLICABLE) BUSINESS ADDRESS CITY ZIP BUSINESS PHONE FAX CURRENT TITLE/POSITION NUMBER OF YEARS IN PRESENT POSITION PRIMARY JOB RESPONSIBILITIES BUSINESS/PROFESSIONAL AFFILIATIONS (IF ANY) 3 P a g e

4 Which of the following best describes your present position? Please check one: o BUSINESS o RELIGIOUS o EDUCATION o SOCIAL SERVICE o GOVERNMENT o VOLUNTEER o INDUSTRY o STUDENT o NON-PROFIT o OTHER o PROFESSIONAL EDUCATION (high school, college, advanced degrees and/or specialized trainings.) Name and Location of School Year of Completion Degree Major a. Please describe three civic, business, religious, political, or social activities in which you have participated. b. List your top three leadership strengths. 4 P a g e

5 PROGRAM PARTICIPATION a. Describe what regionalism means to you. Explain why you think regionalism is important to Middle Georgia? b. What are the three most pressing issues facing Middle Georgia? c. What are the skills needed by leaders in the region to address these issues? d. What will you contribute to the program? e. If selected, what do you hope to gain from the program? 5 P a g e

6 Middle Georgia Regional Leadership Champions Program A Program of the Middle Georgia Regional Commission PARTICIPANT COMMITMENT I have reviewed the Middle Georgia Regional Leadership Champions Program requirements. I understand and certify that 1. I can and will attend all sessions, including the Orientation/Overnight Retreat. 2. I will be fully engaged in all sessions, contribute to my learning, and respect the learning process of my fellow participants. 3. I will apply the leadership skills and knowledge gained in the Middle Georgia Regional Leadership Champions Program toward advocating for regional issues and actively promoting the concept of regionalism in my home community and to others throughout Middle Georgia. 4. No portion of the tuition will be refunded if I cancel or am not able to meet these requirements. 5. I am a resident of one of the following Middle Georgia counties: Baldwin, Crawford, Houston, Jones, Macon-Bibb, Monroe, Peach, Putnam, Pulaski, Twiggs or Wilkinson. SIGNATURE DATE EMPLOYER/SPONSOR COMMITMENT As the applicant s employer and sponsor, I have reviewed the participation requirements of the Middle Georgia Regional Leadership Champions Program. I understand the time commitment required of this program, and will support and facilitate the applicant s participation in the program, should he or she be selected to participate. SIGNATURE DATE TITLE ORGANIZATION/COMPANY 6 P a g e