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Leadership Dixie's Application Form

If you prefer to print and complete the application, please download it and email, mail or fax to:

Lorin Nielsen
170 N. 200 W.
St. George, UT 84770
Phone: (435) 668-0135
Fax: (435) 652-1185
(Please allow six rings for the fax to pickup)
LPNKRN@infowest.com

Contact Information

Last Name:  First Name:  M.I
Nickname:
   
Home Address:
City:   State:   Zip:
Home Phone:   Work Phone:  ext:
Email Address:

Personal Information

Years living in Washington Country as of July 1 of this year:
Have you applied for the Leadership Dixie program before?
If yes, when?
From whom or how did you learn about the Leadership Dixie Program?

Employment Information

Current Position:   Years in the position:
Employer:   Supervisor:
  May we contact your current supervisor as a reference?
His / Her Phone:
Address:
City:   State:   Zip:
   
Role Description:  
 
OTHER WORK EXPERIENCE IN THE LAST 5 YEARS:(begin with the most recent)
Employer - City - State Position - Dates
 
COMMUNITY LEADERSHIP IN THE LAST 5 YEARS:
Describe present and past volunteer community leadership positions you have held.
Organization - Date - Position/Responsibilities
 
EDUCATION: (College/University, Vocational, High School)
School - City - State - Major - Degree
 
OTHER ACTIVITIES AND ACCOMPLISHMENTS IN THE LAST 10 YEARS:
 

Your Views

Approximately how many hours each month do you commit to the following volunteer organizations / activities?
Community:   Religious:   Professional:  
Personal : (identify below)
 
What do you feel are the most pressing problems facing Washington County today that you would like to become more educated about?
 
What special qualities or qualifications do you have and believe will add to the dynamics and diversity of the Leadership Dixie Program?
 

Letters of Recommendation

Please fax or email your letters of recommendation to the email or fax listed at the top of the page.

 

Please note: All applications materials must be submitted by May 15th, preceding the fall in which you wish to participate.

Leadership Dixie 2010-2011
Application Information

Leadership Dixie participants will be selected by a review committee on the basis of completed applications, which must be returned by May 15th, preceding the fall in which you wish to participate. As a follow-up to this application, a personal interview may be requested by the Executive Committee Preference will be given to candidates who, in addition to their potential for Leadership, would contribute to the overall diversity and strength of the class and have available time and resources to commit to the program and future community service. The class is limited to thirty (30) individuals.

REQUIREMENTS FOR SUCCESSFUL PARTICIPATION
The ten (10) month program runs from the August Retreat Workshop through May. It is necessary for the following requirements to be met in order for a participant to graduate:

1. Participation in the Program Sessions –

There are ten (10) sessions including the Opening Session. At least eight (8) sessions must be attended. Except in truly unavoidable situations, punctuality and maintaining presence for the entire session is required.

Under no circumstances may a participant miss any portion of the Opening Session. Failure to attend the entire Opening Session may make it impossible for a participant to continue in the program.

2. Tuition –

Tuition for the Leadership Dixie Program is $500. Applicants will be billed for the tuition upon their acceptance into the program. The individual, employer, agency, organization or other source may pay the tuition. Tuition is due and payable within 30 days of notification of acceptance. Special terms may be arranged upon request.

3. Application Requirements -

Each candidate must submit these items:

(a) Application Form

(b) Letters of Recommendation (letters should reflect both personality/character profiles as well as professional attributes)

   

  • Candidates presenting themselves independently as private
    individuals should submit at least two letters of recommendation from community figures (religious/political/professional)
  • Candidates from sponsor/employer organizations should submit a letter of recommendation from that organization, plus one from a community figure.


For further information, contact:

Lorin Nielsen
170 N. 200 W.
St. George, UT 84770
(435) 668-0135
LPNKRN@infowest.com

 

Participant and Sponsor/Employer Agreement

By submitting this form I (we) agree to have read the above outlined requirements for successful participation in the Leadership Dixie Program and agree to meet all of the requirements as stated.

Name of Organization (if applicable):

Please Note: After submitting this form, if you do not get a confirmation that it has been sent there may be an un-handled error. If this happens please try submitting the form again or contacting the individual listed above.