Howard County Legacy Leadership Institute for the Environment

A. Contact Information

 

NAME

 

STREET / P.O. #

 

CITY / STATE / ZIP CODE

 

(     )                             (       )                                   Morning   Afternoon   Evening

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

 

(    )________________FAX _____________________________________ E-MAIL

 

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

 

NAME:  _____________________________  PHONE NUMBER(S): _______________

 

1.  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 Mondays and Wednesdays, 9:00 to 3:30, from February 1 to March 14, 2012 (with possible snow days March 19 and 21)  We will take off for the President's Day Holiday.

 

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 150 hours of service over six months in one (or more) 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, Friends of Patapsco Valley and 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. 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.  Legacy Leaders will have a variety of opportunities to use current skills or build new ones in the partner organizations. Which skills do you currently have? What are you interested in doing, whether or not you currently have the skills?  (If you have the skill, but don’t want to “use it or learn it”, then check the appropriate skill column but leave the other two columns blank)

 

Please check any or all that apply:                Skills                       I would like to:

                                use it    learn it

1. Small Group Skills                           _______________             _____  ______

2. Research                                        _______________             _____  ______

3. Wildlife Survey/Monitor                    _______________             _____  ______

4. Botany/Horticulture/Gardening         _______________             _____  ______

5. Water Quality Testing                      _______________             _____  ______

6. Resource Management                    _______________              _____  _____

7. Developing new programs               _______________              _____  ______

 

8. Environmental Education – Children _______________              _____  ______

9. Environmental Education – Youth     _______________              _____  ______

10. Environmental Education – Adults   _______________             _____  ______

11. Promotion/PR                               _______________              _____  ______

12. Nature Center Docent/teacher        _______________             _____  ______

13. Trail/Interpretive Guide                  ______________              _____  ______

14. Outreach Programs                       _______________             _____  ______

15. Special Events/Projects Mgt           _______________             _____  ______

16. Cross-Cultural Communication       _______________             _____  ______

17. Public Program Experience             _______________             _____  ______

 

18. Media Design/Illustration               _______________            _____  ______

19. Computer/Technology Use             _______________            _____  ______

20. Administration/Organization           _______________            _____  ______

21. Volunteer coordination                  _______________             _____  ______

22. Grant writing                                _______________             _____  ______

 

 

F. On the back, 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.