Leadership Weekend
Participant Application

February 9-10, 2008

Applications are due by Friday, November 9, 2007.

To apply, please fill out the form below. Part 2 of the form asks a series of questions which may require some thought. We recommend reviewing the form to familiarize yourself before completing. After submitting the form, you will be asked to download a participant agreement form which must be returned to the Center for Student Leadership & Involvement before your application is considered complete.

Part I.
Full Name
Name as you prefer it on your nametag
Campus/Local Address
Local Telephone Number
Cell Phone Number (optional)
Email Address
IM Screen Name
May we include your contact information on a roster to be distributed to all participants ? Yes No
Please tell us about yourself.
Do you identify as

Male Female Transgender

Other

This information is used for rooming assignments. Since this application is not confidential and may be viewed by a committee for participant selection, students who do not identify as male or female may contact Kelly Stevens in the Center for Student Leadership and Involvement in order to address rooming assignments and to maintain confidentiality.

Class Standing

School (Check all that Apply)
First Year
Sophomore
Junior
Business
Communications
Humanities & Sciences
Health Sciences & Human Performance
Interdisciplinary & International Studies
Music
Major
Please help us prepare for your participation
Emergency Contact Name
Relationship
Telephone Number
Are there any special needs as defined by the Americans with Disabiltiies Act (ADA)? Information provided here is intended to assist facilitators to appropriately prepare for participation.

No Yes
If yes, please explain
Dietary Concerns
None Vegetarian Vegan Kosher

Food Allergies, please explain

Other:
Part II
Did you attend Leadership Weekend last year? No Yes
Please briefly respond to the following questions.
1. What do you hope to gain by participating in Leadership Weekend?

2. What is your most memorable leadership experience?

3. What do you wish to improve or address in your own leadership development?
Part III. Participant Fees
Participant fees are non refundable.
$50 - Participant Fee

Once selected, your participant fee is due in the Center for Student Leadership & Involvement by Friday, December 7, 2007. Many students obtain financial assistance in the form of full or partial sponsorship by a campus department, campus employer, or student group. Please review the list of funding suggestions on the CSLI website. If you still need financial assistance contact Kelly Stevens in the Center for Student Leadership & Involvement for assistance in identifying possible options.
Payment Method

If you are personally paying for all or a portion of the fee, complete the following information.
Amount

Cash

 Check
(payable to Ithaca College, list Leadership Weekend on the memo line)
If all or a portion of your fee is being paid by a campus department or student organization, complete the following
Pay by

Charge to Department

Charge Student Organization Acct

The following information allows the Center Staff to contact the department organization directly and arrange payment for your participation. Additional rows are provided if more than one department or organization is providing sponsorship.

Amount to be Charged
Name of Organization or Dept to be Charged
Contact Name Phone
Amount to be Charged

Name of Organization or Dept to be Charged
Contact Name Phone
Amount to be Charged

Name of Organization or Dept to be Charged
Contact Name Phone

TOTAL $

 

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