First Name *

Last Name *

Company *

Company Address *

City *

State *

Enter required value

Postal Code *

Home Address *

City *

Postal Code *

State *

Enter required value

Email *

Cell Phone *

Work Phone *

Please list any special accommodations needed (dietary or otherwise): *

Employer/Supervisor Contact *

Title *

Employer Phone *

Employer Email *

Participant: Why do you want to participate in the Leadership Fort Dodge program? *

Participant: What areas of the community are you most interested in learning about and why? *

Program Dates: *

By checking this box, you acknowledge the dates of all sessions:

Sessions are held on the 2nd Thursday of each month, September through May. Sessions are 8:00am to 5:00pm. Dates for the 2024-2025 program include:

Thursday, August 29, 2024 - Orientation

Thursday, September 12, 2024 

Thursday, October 10, 2024

Thursday, November 14, 2024

Thursday, December 12, 2024

Thursday, January 9, 2025

Thursday, February 13, 2025

Thursday, March 13, 2025

Thursday, April 10, 2025

Thursday, May 8, 2025

Thursday, May 15, 2025 - Lunch Graduation

**Please note the attendance requirements (listed below) apply for each of these sessions.

Participant Expectations and Program Requirements: *

By checking this box, you acknowledge the program expectations & requirements. 

• Each participant is expected to attend one Fort Dodge City Council meeting or Webster County Board of Supervisors meeting.
• Each participant must complete one volunteer/service activity outside of the session during the course of the program.

Attendance Requirements: *

• Each participant is allowed ONE absence during the duration of the program.
• Participants who have more than one absences will be given the opportunity to make up the absence with an additional service project.
• Any no call/no show may result in immediate removal from the program.
• ***If you know that you will not be able to meet this attendance requirement, please do not apply to participate.***

By signing and submitting this application, I acknowledge receipt of the above attendance policy and understand what is expected of me as it relates to Leadership Fort Dodge and attendance. I also agree to pay the fee of $500 and understand that refunds will not be issued to participants who fail to meet the expectations of the program or who leave the program following the August 29 orientation. 

Applications are not considered complete until both the the application & $500 fee are received. 

Participant Signature: *

Participant Printed First & Last Name: *

Date: (MM/DD/YYYY) *