COMMONWEALTH INSTITUTE FOR PARENT LEADERSHIP
Northern Kentucky

First Name:
Last Name:
Street Address:
City:
County:
State:
Zip:
Home Phone Number:
Cell Phone (optional):
Work Phone:
Select which phone number at which
you would like to be contacted:
E-mail:
Emergency Contact Name:
Emergency Contact Phone Number:
Employment (Current):
Race/Ethnic Origin (optional):


PERSONAL COMMITMENT
I understand participation in the Commonwealth Institute for Parent Leadership requires attendance at three two-day trainings and a commitment to work with my school to plan and implement a project designed to improve student achievement. If space is available for me in this program, I agree to participate in all six days of training and conduct at least one project.

I agree to the terms set forth in the personal commitment paragraph above by checking this box.

VOLUNTEER EXPERIENCE

Are you involved with:
Role:
School Board?
SBDM Council?
SBDM Committee?
PTA/PTO?
Community Committee?
Church /Scouts?
Other?


PERSONAL INFORMATION

Please tell us about your children:
Name
 Age Grade Current School School will attend in Fall 2010

OPEN RESPONSE
What school do you plan to work with during your two year committment?
Who is the principal?
List some ways you are currently involved in, or would like to be involved in your child's school:
List any issues or problems your school/school district is currently experiencing:
Tell us about any ways you are involved in your community:

LEADERSHIP SURVEY

The following list indicates leadership characteristics.  Rate yourself on each:
Indicate your thoughts about your own leadership.
Using the scale below, check the number that best represents YOUR response to each item.

Statement
 Rating
I know nothing important gets done alone.
I find that making things happen and doing a good job takes lots of planning.
I am often restless with the status quo.
My children have taught me important ideas about leadership and working with others.
I use my personal experiences to relate to others.
If I come to a dead end, I find another way to tackle the problem.
My co-workers and/or family say I follow through with my commitments.
I deal openly and honestly with conflict.
I like to set goals and measure my success.
 

RELEASE TIME FROM EMPLOYMENT (Optional)

Since participation in the Commonwealth Institute for Parent Leadership involves attending meetings during the work week, we are willing to contact your employer to explain the importance of the Institute and encourage your employer's support. The purpose of our letter is NOT to request time off for you. It is very important that you discuss your interest in attending the institute with your employer. If you feel that a letter from the Prichard Committee would help you, please give us the name, title and address to write to.

NOTE: A letter explaining the purpose and content of the institute will be mailed to your employer no later than two weeks prior to the first session. It is YOUR responsibility to contact your employer ahead of time to ask for the time off.

NOTE: A letter explaining the purpose and content of this project will be mailed to your employer. It is YOUR responsibility to contact your employer ahead of time to ask for the time off.
Participant's Name
Employer's Name
Supervisor's Name
Supervisor's Title
Address
Participant's Job Title

ATTENDANCE POLICY

Participants are required to attend all day and evening sessions.
Participants need to make arrangements in advance in order to attend all sessions.

I agree to the above attendence policy terms.
After submitting please return to the home page for the reference form.
Each application needs to have at least one reference to be considered.