Leadership Greater Hartford’s Third Age Initiative
Enrollment Application
Please return to Leadership Greater Hartford, Third Age Initiative, 30 Laurel Street, Hartford, CT 06106
Name _______________________________________ Nickname______________________________
Street Address________________________________ City____________________ State__________ Zip ________ Telephone (____)__________ E-mail ________________________________________
1a. Are you presently retired? 1b. Are you employed? Part-time Full time
Business/Organization
Title
Business Address
Business Phone
Fax
Business E-mail
2. The Third Age Initiative seeks to identify participants with different community and leadership experiences. The program will be designed to build upon your past experience and knowledge and to enable you to become a resource to your classmates. To help us meet our goals, please tell us about community, civic, professional, business, religious, social and other organizations of which you are or have been a member. Please also tell us about any responsibilities you have held in those organizations. Please use a separate sheet of paper if necessary.
3. Please tell us about your employment history and careers you have pursued. You need not tell us about all jobs over your entire lifetime, but tell us whatever will help us know about your interests and experience. You may also simply attach a resume.
(Please turn over and continue the application)
4. What would you like to gain from
the program, and what do you believe you can contribute by becoming part of
this community leadership development program?
Our funding sources require that we report on the demographic make-up of the class. Please assist us by providing the following information.
Gender: Male Female Marital Status: Married Single Divorced Widowed
Race/Ethnicity: Asian Native American African American Caucasian Hispanic Other
Date of birth__________________________________
Household Income: Under $16,700 $16,700 - $22,500 $22,500-$50,000
$50,000 - $75,000 $75,000-$100,000 Over $100,000
Educational Background (check all that apply):
Less than high school High school diploma Some college
Associates Degree Bachelors Degree Some graduate work
Masters degree Professional degree Doctoral Degree Post-graduate work
Participant Responsibilities
Participants will be notified in writing that their application is accepted for enrollment.
Program requirements:
1. Attend an information session and interview.
2. Attend five weekly workshops (9:30 a.m.-4:00 p.m.) and one overnight retreat.
3. Participate on a team to plan and implement a community project aimed at building a stronger, more unified community. Teams will complete their work one year after the class begins.
4. Attend 4 additional class workshops throughout the year.
5. Pay $75 tuition in 3 installments. Scholarships are available. See below.
Participants who are absent from three or more workshops and/or are inactive within their task forces will not graduate from the program.
Leadership Greater Hartford values a class that reflects the diverse interests, experiences, perspectives and backgrounds of the larger community. In addition to completing this application, please use a separate sheet of paper to give us any additional information that you think we should know. In submitting this application, you signify your intention to meet the requirements of the program as stated above.
I am interested in applying for scholarship in the amount of: $25 $50 $75
I would like to contribute a scholarship in the amount of: $75 $150 $225 other_____