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Applicant Name:
Email:
Address:
City:
State:
Zip Code:
Phone Number:
Name of Organization & Job Title
Gender
Female |
Male
County of Residence:
Hillsborough |
Pinellas |
Other
Age Range:
15-19 |
20-29 |
30-39 |
40-49 |
50-59 |
60+
Race:
African American |
Asian |
Caucasian |
Hispanic |
Other
Primary area of interest(s)
Affordable Housing
Senior Issues
Faith-based
PTA/Schools
Health and Nutrition
Community Cleanup
Economic/Business Development
Neighborhood Associations
Youth/Civic Engagement
Crime/Community Safety
Parks/Beautification
Other (please list separated by commas):
What skills need improvement for you to be a better leader?
What issues do you want addressed/changed in your community?
What do you hope to accomplish with your training?
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 a two day session
and I agree to complete all of the two sessions
to receive the program Certificate of Completion, and to be
eligible for other benefits associated with this program.
Jim Walter Partnership Center ♦ University of South Florida ♦ 4202 E. Fletcher Ave MGY132 ♦ Tampa, FL 33620 ♦ (813) 974-5709
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