engage . learn . play

First Name:

Last Name

Phone:

Email:

Major:

Year:

Residency:

Please check all the items below that will apply to you in the spring 2008 semester:

I will have a part time job

I will have a full time job

I will be on co-op

I will have a work-study job

Please select from the options below the sessions of which you can attend

Mondays, 5:00-6:30 p.m.

Tuesdays, 2:30-4:00 p.m.

Tuesdays, 4:30-6:00 p.m.

Wednesdays, 5:00-6:30 p.m.

Any session is fine

None of the above work for me

* every effort will be made to place you into your desired session

Do you foresee any scheduling conflicts with full participation in the program? If so, please describe below:

Please list the activities in which you have participated or currently participate in at Wentworth:

Position Held (If Applicable)

Organization/Activity

Briefly describe your reasons for applying for the Emerging Leaders Program.

Please consider the following quote and briefly explain its meaning:
"Leadership and learning are indispensable to each other." - John F. Kennedy

What do you hope to gain and/or learn from participating in this program?

To the best of my knowledge, the information I have furnished on this application is true and correct. I realize that intentional falsification of information provided on this application will subject me to disqualification as an applicant. Additionally, I give permission for the Office of Student Leadership Programs to check my academic and disciplinary standing.

Selecting "Yes" will be considered your signature
(it is required)

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