San Rafael Leadership Institute Application

San Rafael Leadership Institute Application

Completed applications and tuition must be received by 5 pm, September 13, 2024
Contact Information

Your Name

First Name *

Last Name *

Company *

Job Title

Phone Number *
Please do not add any characters or dashes

Email Address *

Best Time to Reach You

Daytime Evening

Emergency Contact Phone Number *
Please do not add any characters or dashes

Name of Supervisor

First Name

Last Name

Email of Supervisor *

Please list any food allergies (Lunch will be provided during IN-PERSON sessions.)

Briefly describe your work responsibilities *

Personal Objectives & Priorities: (Please attach a separate page if necessary)

1. Please list the issues you feel are most important to the future of San Rafael and Marin County. *

2. What leadership opportunities interest you (e.g., developing a personal leadership vision, excelling in executive management, serving on boards or commissions, running for public office)? *

3. What do you hope to gain from your Leadership Institute experience? *

Upload File (Optional)

Community Involvement

Please list recent involvement in community, professional, service or nonprofit organizations, including the organization name, dates of participation, and position or role.

Participation Agreement

The full participation of participants is expected to guarantee a successful program. Participant guidelines include but are not limited to: The 2024-25 class cohort will follow the COVID-19 guidelines as established by the County Public Health Officer, attendance at all monthly sessions, October – June 2025, sessions are from 8:30 am-5:00 pm in-person, using safe and appropriate guidelines approved by Marin County Public Health officials, all absences must be communicated prior to class via text or email within 24 hours to the Program Director or Program Chair, except for unexpected emergencies, absences will be monitored throughout the year, and if there are questions about eligibility for graduation, it will be handled on a case-by-case basis, participants are expected to arrive on time and be present for the entire session, participants are expected to turn all cell/smartphones on silent or vibrate during the session and conduct any business (e.g., phone calls, voicemail, emails, or texts) during breaks or lunchtime, and participation in the class project is mandatory and will require additional planning time outside of the monthly sessions.

I understand the requirements of the program and am aware that completion of this application does not ensure my acceptance into the San Rafael Leadership Institute. *

Yes No

I have read the guidelines and agree to abide by the tuition and participation requirements. *

Yes No

My employer has been notified of my intent to participate in the program, endorses my involvement and agrees to allow me time off work to attend all sessions. *

Yes No

Applicant Digital Signature

Date *
Format: M/d/yyyy

Supervisor Digital Signature *

Date *
Format: M/d/yyyy

Payment

Please mail the application and full payment to: San Rafael Chamber of Commerce, 817 Mission Avenue, San Rafael, CA 94901 Phone: 415 454-4163 Checks payable to the San Rafael Chamber of Commerce or call the office with a credit card number to secure your spot.
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