Application Form - 2013

Howard County Legacy Leadership Institute for the Environment

      Application for Class of 2013 (download, fill in and submit by email to hocollie@gmail.com or send by USPS to Barbara Schmeckpeper, 6305 Summercrest Dr., Columbia, MD 21045)
 

A. Contact Information

 

NAME ______________________________________________________________

 

STREET / P.O. #______________________________________________________

 

CITY / STATE / ZIP CODE_______________________________________________

 

(      )___________            (       )_____________         Morning   Afternoon   Evening

TELEPHONE (DAY)             TELEPHONE (EVENING)             BEST TIME TO CALL

 

E-MAIL _____________________________________________________________

 

 

IN CASE OF EMERGENCY, CONTACT PERSON’S TELEPHONE(S):

 

NAME:  ____________________________  PHONE NUMBER(S): _______________

 

 

How did you hear of this Institute?  ______________________________________

 

 

B. Availability for Legacy Leadership Institute for the Environment

Classes for the Howard County Legacy Leadership Institute for the Environment (HoLLIE) will meet Tuesdays and Thursdays, 9:00 to 3:30 (or 4:00), from January 31 through March 14, 2013 (with possible snow days in March; no class on Tuesday after President’s Day).

 

1. As far as you know now, will you be able to attend all class sessions?

____ Yes _____ No (please describe:_____________________________________

___________________________________________________________________

 

2. In HoLLIE’s field placement phase, volunteers commit to 100 hours of service over six months in one of our partner environmental organizations. As far as you know now, can you commit to that volunteer service?

____ Yes       ____ Not sure (please describe): ______________________________

 

What restrictions (e.g. physical, travel, caregiving) do you have on your service?

 

 


C. Background Information

1. Are you: ____ Male____ Female

2. What year were you born?     19_____

 

3. What do you consider to be/have been your primary career(s)? ______________

 

4. Are you currently employed in a paid position? ____ No ___Yes (# hrs/wk_____)

 

5. If so, what is your current paid employment? ___________________________

 

6. Have you volunteered with partner or other environmental organizations (e.g., Howard County Conservancy, Bird Club, Garden Clubs, Master Gardeners, Patapsco Heritage Greenway, Climate Change Initiative, Howard County Recreation and Parks)?

If yes, please describe below. ____ No  ____ Yes

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

 

7. Describe other community service or activism: ___________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

 

8. Describe other experiences (professional certifications, programs completed, training or special licenses) that may assist in your Legacy Leadership Institute work:

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

 

9. Are you fluent in a language other than English? ___ No ___ Yes

If yes, which?  ___________________________

 

10. We regret that we need to ask: Have you ever been convicted under criminal or military law, forfeited bond or collateral, or are criminal charges currently pending against you? (Not including minor traffic violations or any offense settled in juvenile court or under a youth offender law.) _____No ______Yes 

(If yes, attach a detailed explanation about the nature of conviction, degree of rehabilitation and if applicable, how long it has been since you were released. This will not automatically disqualify you from the HoLLIE program.)

 


D. Interests and Experiences:

1. What do you hope to give/gain through participating in Howard County’s Legacy Leadership Institute for the Environment?

 

GIVE:____________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

 

 

 

GAIN:_____________________________________________________________

_________________________________________________________________

_________________________________________________________________

 _________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

 

 

E.  Please describe any additional avocations, interests, or skills that apply to your prospective volunteer participation in the Howard County Legacy Leadership Institute for the Environment.

 

 

 

 

 

 

 

 

 

 

 

Please NOTE:  There is a $75 materials fee for participants in the course.  Interviews will begin in October and continue until the class is full (limit, 15 participants).

ĉ
Cathy Hudson,
Sep 19, 2012, 5:35 AM
Comments