Contact Information

First Name

Last Name

Name as you want it to appear on your name tag:

Cell Phone

Home Address

City

Spouse Name

Names of Children

Work Address

City

Zip Code

Current Employment

Present Employer

Position

Previous Employment

Employer 1 (list most recent first)

From

Title/Responsibility

Employer 2

From

Title/Responsibility

Employer 3

From

Title/Responsibility

Education

School 1 (Name and City of School)

From

Degree

School 2 (Name and City of School)

From

Degree

Organizations & Activities

Organization 1

Length of Membership

Official Position(s) held

Organization 2

Length of Membership

Official Position(s) held

Organization 3

Length of Membership

Official Position(s) held

Additional Organizations you'd like to list

How much time each month do you commit to community, civic professional, or other organizations or activities?

What do you consider to be your most important community service accomplishment to date?

General

What are the two most notable opportunities that North Central Kansas has to offer?

What do you feel should be done to develop one of these?

What do you feel are two of the most significant challenges facing North Central Kansas today?

What do you feel needs be done to develop one of these?

What are your long-term goals? What role do you see yourself in 5 years from now (whether in business, politics, or the community)?

What do you hope to gain from your Leadership Mitchell County experience?

References

Reference 1- Name

Title

Phone

Business Address

Reference 2 - Name

Title

Phone

Business Address

Reference 3 - Name

Title

Phone

Business Address

I understand I am expected to attend all sessions

Commitment to Session Dates & Program Qualifications

Session dates & program qualifications are listed HERE. Please confirm that you understand expectations and are available to commit to all of these dates. If you are unable to make it to all the sessions we ask that you consider applying next year.

2nd Year Commitment

As a graduating class member of LMC - 2nd year participation requirements include:

Co-facilitating a minimum of one class session alongside LMC board members during the 2026-2027
Participating in a planning workshop held in July of 2026 to prepare for next year's program
Participating with your fellow class members as hosts for the evening meal during the September 2026 class session located at Ringneck Ranch

I agree to the 2nd year commitments

Tuition

Tuition for the class is $300. If accepted, who will be paying your tuition?

Download

If you are an employer-sponsored applicant please download the Authorization to Participate form. This form is required before acceptance into the program can be granted.

Thank you for submitting your application to LMC! If you have any questions, please do not hesitate to reach out!

Signature

Upload Employer Authorization

Thank you for your interest in Leadership Mitchell County.

Our 2026-2027 Application will be open April 1, 2026!

Keep Me Informed!

Contact Information

Current Employment

Previous Employment

Education

Organizations & Activities

General

References

Commitment to Session Dates & Program Qualifications

2nd Year Commitment

Tuition

APPLY