Leadership Canadian County

Confidential Application
Please type of print and limit your answers to the space provided. Leadership Canadian County participants are selected without
regard to sex, race, age, national origin, or handicap status.
Personal Information:

Last

First

MI

Preferred Name

Home Address

City/State/Zip

Phone

Employer (If Applicable)

Position/Title

Phone

Employment Address

City/State/Zip

Fax

E-mail Address
Preferred mailing address:

Home

Employment

Education:
Please indicate your academic background, training & continuing education experiences:

How long have you lived in Canadian County?______________________________________________________________________

How long have you worked in Canadian County?____________________________________________________________________
Participation:
Do you have the support of your employer for the time required to participate in Leadership Canadian County?

Yes No

Tuition:
Leadership Canadian County tuition is $250. Tuition is to be paid prior to the start of the program.
Financial Assistance:
I would like to be considered for financial assistance so that I may attend Leadership Canadian County

Yes No

Application and Mailing Deadline:

To be eligible for consideration in the Leadership Canadian County Class for 2015-2016, application must be received no later than
August 24, 2015. Send completed application to Kenzi.hull@redlandscc.edu or:
Leadership Canadian County
Redlands Community College
Attention: Kenzi Hull
1300 S. Country Club Road
El Reno, OK 73036-5304
Signature:
I understand that participation in ALL programs is mandatory for graduation from Leadership Canadian County.

Signature of Applicant

Date of Application