CFLE Application Draft

CFLE Application

Class ####
Thank you for your interest in CFLE. Please complete each section of this confidential application in full. Note: Once you start the application it must be
finished and submitted; there is no saving and editing at a later time.
This application is due no later than ## DATE ##

Class participants will be chosen by the CFLE Advisory Committee based on
leadership potential, community service, ability to comply with the time commitment required and the participants ability to utilize the skills gained through this program on a long-term basis to benefit our community. Appointments to each Class are limited.

Once selected, class members will participate in monthly sessions in addition to preclass activities and a service project. Tuition is non-refundable and all applicants
must have full, written support of the organization they represent.

Any questions please contact Lisa Disabato Moore, CFLE Program Coordinator at
ldisabato-moore@juvenilecourt.summitoh.net
Name

First NameLast Name
Employer
Job Title
How long have you been in this position?
Professional Licences/Titles (PhD., LSW, etc.)
Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Email Address
example@example.com
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Education-College/University (Undergraduate)
Name of School
Date of Graduation
Major/Area of Study
Degree
Any additional information:
Education-College/University (Graduate/Advanced)
Name of School
Date of Graduation
Major/Area of Study
Degree
Any additional information:

Employment Responsibilities & Community Involvement
Employment Responsibilities
Briefly describe your current employment responsibilities
Community Involvement
Name of Organization(s)
Position(s) Held
Additional Information

What particular strengths and experiences do you bring to the CFLE Program?
Identify one problem related to Social Services facing Summit County residents and discuss an approach to solving it:
References

Reference #1
Name and Title
Business/Organization
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Reference #2
Name and Title
Business/Organization
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com

Sponsoring Organizations Agreement

This applicant has the full support of the below person/organization for the time commitment required to participate effectively in the Child & Family Leadership Exchange Program during the upcoming year.
Organization Name:
Director/CEO Name:
Phone or Email:
Date

MonthDayYear
Date
Tuition Agreement

If selected to participate in the CFLE program you or your sponsoring organization agree to pay the $1200.00 non-refundable tuition fee no later than August 30, 2024. The tuition covers the cost of this 11 month program including the overnight retreat and monthly sessions. A limited number of scholarships may be available; please see additional questions on this application for information.
Yes- I and my organization accept the responsibility for the $1200.00 tuition if I am chosen as a CFLE Class ## CLASS ## participantI would like to apply for a scholarship at this time (answer required to next question)
Scholarship Request: A limited number of full/partial scholarships may be available. To be considered please explain below your agency's need for the assistance and how your agency will benefit from having a participant in the CFLE program.
Attendance Agreement & Signature:
By entering your name below you are completing your application to become a
member of the Child & Family Leadership Exchange Class ## CLASS ##. You fully understand that attendance at monthly sessions are mandatory. Though emergencies do arise, class members missing more than 2 sessions may not graduate unless given the opportunity to make-up work/activities as determined and approved by the Session Chairs/Advisory Committee.

Furthermore, you understand that upon acceptance into the program a written
agreement complying with tuition and attendance requirements will be completed by you and your sponsoring agency/organization.

You agree to all of the terms outlined in this application and are ready to take on a leadership role within this opportunity!
Name

First NameLast Name
Date

MonthDayYear
Date
Should be Empty:

CFLE Application

Education-College/University (Undergraduate)

Education-College/University (Graduate/Advanced)

Employment Responsibilities & Community Involvement

References

Sponsoring Organizations Agreement

Tuition Agreement