Leadership Henry Application - Henry County Economic Development Authority

Your Personal Information

Your Name(Required)

First Middle Last

Preferred Name

Home Address(Required)

Street Address Address Line 2 City State ZIP Code

Your Email Address(Required)

Your Phone

How long have you lived or worked in Henry County?(Required)

Age

Race/Ethnicity

Gender

Sponsor

Sponsor Company Name

Contact Name

First Last

Contact Phone

Sponsor Address

Street Address Address Line 2 City State ZIP Code

Employment

Company Name(Required)

Business Address(Required)

Street Address Address Line 2 City State ZIP Code

Work Phone(Required)

Mobile Phone(Required)

Business Email

Length of Employment

Current Position/Title

Responsibilities

List previous professional employment (reverse chronological order). Include military duty.

Click the "+" to add more employers.

Employer

Title/Responsibility

Year

Education

High School

City

Degree/Year

College

City

Degree/Major

College

City

Degree/Major

Are you a graduate of another leadership program?

Yes

No

If yes, which one(s) and when?

Community Involvement

Organizations

Please list, in order of importance to you, civic, political, governmental, religious, social, or other activities. (Click + to add more organizations)

Organization

Position/Year

Are you, or your employer, a member of a Chamber of Commerce?

Yes

No

If yes, which one(s)?

Me

My Employer

Both

How are you currently involved or engaged in Henry County?

What is your most significant volunteer service accomplishment?

What is one area that you can significantly contribute to the improvement of Henry County?

Please tell us what you hope to gain from your Leadership Henry experience.

What do you feel are the most significant problems facing Henry County?

Tell us something interesting about yourself that is not already reflected on this application.

Recommendations

Sponsor

This candidate has my full support to participate in Leadership Henry. I am aware of the time commitment involved with his/her effective participation and/or the financial obligation. (This must be signed by the applicant's immediate supervisor, if other than the applicant.) Typing your legal name on the below signature line serves as your signature.

Name

First Last

Title

Organization

Date

Signature

Personal Recommendations

Please list two people, other than your sponsor, who are knowledgeable about your leadership performance and potential.

Name

First Last

Phone

Organization

Title

Name

First Last

Phone

Organization

Title

Program Commitment(Required)

Attendance is mandatory.

To graduate from Leadership Henry, a participant is expected to attend at least six of the eight full sessions. Absenteeism will result in your being dropped from the program.

An Orientation/Opening Retreat will be September 15, 2026. Attendance is mandatory.
A community service project, to be determined by the participants, will be conducted in December in place of the monthly session that month.
Sessions will be one full day per month, running approximately 8:00 a.m. to 4:00 p.m.

If accepted into the program, the applicant will be billed for tuition of $250 which will be due no later than Friday, September 6, 2024. Tuition covers the program costs, printed materials, and food. Tuition is non-refundable, in whole or in part, in the event the applicant fails to complete the program due to non-attendance or for other reasons.

I understand

Waiver & Acceptance(Required)

I understand the goals and commitments of the Leadership Henry program. If selected, I will devote the required time and dedication to the program.

By signing this application, I hereby authorize Leadership Henry to use, reproduce, and/or publish photographs and/or video that may pertain to me – including my image, likeness and/or voice without compensation. I understand that this material may be used in various publications, public affairs releases, recruitment materials, broadcast public service announcements (PSAs) or other related endeavors. This material may also appear on the Henry County Economic Development Authority’s website and social media pages. This authorization is continuous and may only be withdrawn by my specific recission of this authorization. Typing your legal name on the below signature line serves as your signature.

I understand

Applicant's Signature

Date

Polo Style Shirt Size(Required)