Name:          ___________________________________________________

Address:       ___________________________________________________

Address(2):   ___________________________________________________

City: _________________________________ St: __________  Zip: ______________

E-Mail: _________________________________________________________

Phone   (H):_____________________(W):_____________________(C):_____________________

List Past and Present business, civic, community and volunteer activities in which you have participated:

Provide two references who can discuss your qualifications to participate in Leadership Evergreen:

Name:  ________________________________     Name:   ________________________________

Phone:  ________________________________     Phone:  ________________________________

How Are you Acquainted?                                   How Are You Acquainted?

Please identify and discuss one particular issue, opportunity or problem you feel is important to the mountain community:

How do you hope the Leadership Evergreen program will help you fulfill your aspirations as a leader or volunteer in the mountain community:

o Tuition is $550. A few partial scholarships are available. Please check the box if you need
         financial assistance to attend this program.

Participants Agreement:
If accepted as a participant in the Leadership Evergreen program, I agree to the following:

During the program: attend all sessions ( More than two absences will delay graduation) and participate in a class project.

Following graduation: seek opportunities to utilize leadership skills and abilities for the good of the mountain community; sustain and perpetuate the Leadership Evergreen program.