“Come on, get involved....it’s your community!”

2011 Class

INCOMPLETE AND/OR UNSIGNED APPLICATIONS WILL NOT BE CONSIDERED

  • Participants must make a commitment to attend ALL sessions
  • Participants must be at least 18 years old
  • Participants must provide their own transportation to all sessions
  • Participants will be required to wear appropriate attire at all class sessions
  • Participants are required to conduct themselves in a professional manner at all times to assure that each session is a positive experience. Failure to comply shall lead to dismissal!
  • Participants are not permitted to bring weapons of any kind to any class session
  • Participants must sign this application acknowledging Release of Liability
  • Participants living within the City of Buckhannon and Upshur County will be given enrollment priority
  • Participation is permitted only for those who have not previously attended the Buckhannon-Upshur Citizen’s Leadership Institute of Governmental Affairs
  • PARTICIPANTS MUST ATTEND AT LEAST 8 OUT OF THE 10 SESSIONS IN ORDER TO RECEIVE A WVWC CEU CERTIFICATE AND PARTICIPATE IN GRADUATION

CONTACT INFORMATION: Phone numbers, email address and/or other contact information will be entered into record-keeping and system for program management purposes ONLY.

RELEASE OF LIABILITY: I hereby request authorization to participate in the Buckhannon-Upshur Citizen’s Leadership Institute of Governmental Affairs. I understand that tours and other activities may include a risk of personal injury and/or personal property damage; and I make this request with full knowledge of these risks. I agree to hold the City of Buckhannon, the Upshur County Commission, and the West Virginia Wesleyan College and their respective agents, volunteers and personnel, harmless from any and all claims, actions, suits and/or injury that may arise from my participation in the Buckhannon-Upshur Citizen’s Leadership Institute of Governmental Affairs.

PHOTOGRAPHS: I authorize the use of any photograph(s) and/or videotape taken in connection with my participation in the Buckhannon-Upshur Citizen’s Leadership Institute of Governmental Affairs program without prior approval or compensation by any local, state, national and/or West Virginia Wesleyan College program representatives or their affiliates.
By executing this form and affixing my signature below, I certify that I have truthfully answered, and have read and carefully examined the Release of Liability in its entirety and understand all of its terms, and have had any questions regarding the Release of Liability or its effect answered. I understand that my submission of this form, whether mailed; or sent electronically via email or faxed, shall have the same force and effect as an original I sign this release freely and voluntarily. I also understand that my submission of this application does not guarantee my admittance.

COST: FREE OF CHARGE TO BUCKHANNON & UPSHUR COUNTY RESIDENTS, AGE 18 AND OLDER

Name:
Title:
Address:
City:
State:
Zip:
Work Phone:
Home Phone:
Cell Phone:
Occupation:
Emergency Contact:
Email:
Education Background:

HS/GED

AA

BA

Masters

Higher

City of Buckhannon Resident:

Yes

No

If not, please specify city:

Upshur County Resident:

Yes

No

If not, please specify county:

Do you own a business in Buckhannon or Upshur County?

Yes

No

If yes, what is the business name:

Have you ever served on a board or commission for a local government?

Yes

No

T-shirtsize:

S

M

L

XL

XXL

Reason for attending:
How did you learn about our program?

Newspaper

Family/Friend

Internet

Flyer

TV

Radio

Other: