Grassroots Leadership College Participant Application
Personal Information:
Name ____________________________________________________________________________
Home Address _____________________________________________________________________
City _________________________________________________ Zip_________________________
Phone Number (Evening) __________________ Phone Number (Daytime) ______________________
Email address (if applicable) ______________________ Date of Birth (optional)__________________
Employment Information:
Occupation/Retired ___________________________________________________________________
Employer’s Name/Retired From ________________________________________________________
Short Answer Questions:
Please tell us a little more about yourself by answering the following questions. Your answers do not need to be long – no more than a few sentences.
1. Please review the criteria and time commitment for participation in the Grassroots Leadership College and tell us why are you interested in participating and what you’d like to learn.
2. What neighborhood do you live in?
What do you like about it?
What do you dislike about it?
3. What are some ideas you have for a neighborhood or community project that you would like to work on through the GLC?
4. Have you been involved with any neighborhood, school, or community groups, and, if so, which ones? If not, what kinds of groups are you interested in being involved with?
5. Have you ever been mentored or coached by someone, formally or informally? YES NO
If so, what did you like about the experience?
What did you dislike about the experience?
6. Individuals you have met or would be interested in having as a mentor/coach:
7. Could you commit 3-5 hours/week to the GLC (including time spent on your neighborhood/community project)?__________
Personal References:
We encourage you to attach up to two letters of support from individuals or groups that are familiar with you or your community involvement
The GLC will provide childcare, transportation, and meals for our participants, as well as other accommodations that make participation possible. Please let us know of any special needs you may have.
Please return the completed application form to the Grassroots Leadership Coordinator at 1321 E. Mifflin Street, Suite 201, Madison, WI 53703. Questions? Call 441-0085.