GIL Application

Personal Information

Please fill out the following information in it's entirety for application consideration

Name:*

First

Last

Address:*

Street Address City State / Province / Region Postal / Zip Code Country

County of Residence (Example: Gwinnett, Dekalb, Whitfield):*

How many years have you lived in your county? (Not country).

Gender:*

Gender Non-Conforming

Female

Male

If 'Other' please specify:

Date of Birth:*

day

/

month

/

year

Telephone:*

Area Code

-

Phone Number

E-mail:*

Will you be applying for a scholarship and/or payment plan?*

Please indicate whether you will be applying for a scholarship. If the answer is "Yes" or "Maybe," you must indicate a value in the next question.

Annual Household Income (approximate) :*

Mandatory if Scholarship is requested. Otherwise, you may enter a value of $0.

Education

This section pertains to additional personal information regarding your education. Leave sections blank if they do not apply to you. This section is for our records only, neither education level nor field of study will have any bearing on program acceptance.

High School: Years of Study:*

High School: Have you graduated?:*

Yes

No

College: Years of Study:*

College: Have you graduated?:*

Yes

No

College: Degree :*

College: Major :

College: Minor :

Post Graduate: Years of Study :

Post Graduate: Did you Graduate? :

Yes

No

Post Graduate: Degree :

Awards/ notable commendations/areas of development/certifications:

Leadership/Community Experience

Let us know of any employment, scholarly, or community activities you have been active in so far, if any.

List organization(s) and position or level of involvement:

Describe the impact that this involvement has had on you, the organization and beyond.

List skills acquired through participation and how you plan to use them in the future:

Commitment

In this section you'll provide your reasons for participating in this training, how do you see using these skills, and a sense of your level of commitment to active participation in community life.

List three ways you hope to benefit from this program:*

List three skills you hope to improve on through this program:*

What impact do you intend to have your community as a result of the GALEO Institute for Leadership?*

Can you commit to being present to every session outlined in the program calendar and to complete the group project and community activities mandatory for the program?*

Yes

No

Yes - with reservations

If you answered "Yes - with reservations" above, please indicate what those reservations would be:

Awareness & Interest Areas

This area pertains to your awareness of community issues and your interests in participating in community improvement.

Identify and describe one area of need in your community and propose a tangible solution that would address this need. Make sure to justify your solution and the reasoning behind it (e.g. Fixing childhood obesity in your neighborhood with a fun fitness program at the local park.)*

How did you hear about the GALEO Institute for Leadership?:*

References

Please provide the name and contact information of a reference that can attest to your involvement in the community.

Reference Name:*

First

Last

Reference's Title/Position:

Reference Telephone:*

Area Code

-

Phone Number

Relation to Reference:*

Reference E-Mail*

888.54GALEO

Personal Information

Education

Leadership/Community Experience

Commitment

Awareness & Interest Areas

References

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