United Way of Berks County

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Full Name:

Nickname:

Formal Name (preferred appearance in listings and official documents):

Home Address

Address Line 1:

Address Line 2:

City:

State:

Zip Code:

Home Phone:

Cell Phone:

Office Phone:

Preferred Phone:

Home

Cell

Office

Personal Email:

Business Email:

Preferred Email:

Personal

Business

Note: communication will primarily be via email.

Organization/Employer:

Job Title:

Employer Address

Address Line 1:

Address Line 2:

City:

State:

Zip Code:

Personal Information

Birth Year:

Preferred Pronouns:

Ethnicity:

Do you have any special physical needs for which you request accommodation?

Yes

Please describe:

Do you have any dietary restrictions?

Yes

Please describe:

Something interesting about yourself:

Do you have access to the following to utilize Virtual Meeting Platforms? Please check all that apply.

Computer

Laptop

Smartphone

Internet

Wi-Fi

Sufficient/Unlimited Data

Program Applying For

Blueprint for Leadership

Leadership Berks

Sponsoring Organization

Executive Contact to Acknowledge for Sponsorship:

Job Title:

Email Address:

Business Address

Address Line 1:

Address Line 2:

City:

State:

Zip Code:

Tuition Invoice to be sent to:(if different from executive contact)

Name:

Job Title:

Email Address:

Telephone:

Referral Source:I learned about this program from:

Emergency Contact Information

Emergency Contact:

Relationship:

Telephone:

Community Placement Requirement

One major requirement for the UWBC's Leadership program is to have participants volunteer their time and talent to committees, community groups, or not-for-profit organizations following graduation.

What attributes, skills and experience would you bring to a nonprofit board or committee?

Nonprofit Board and/or Committee Experience:

	Organization Name:	Focus of Agency:	Position Held:	Start Date:	End Date:	Contact Name:	Contact Phone:	Contact Email:

* Please upload a copy of your resume or summary of professional and life experience:

Choose File

* Please enter in your t-shirt size (for unisex shirts), as all participants will receive a shirt. *Please note we only carry sizes S, M, L, XL, XXL and 3XL.

* Would you prefer a crew neck or a v neck tshirt?

Volunteer Interest

If I could volunteer time for one cause, it would be:

If unsure, to help narrow down your interest areas, select any of the following categories in which you would like to serve after you complete the program.

Infants/Preschoolers (0-4)

Children (5-12)

Adolescent (13-17)

Young Adults (18-25)

Older Adults (55+)

Families/Parents

Nursing Homes

Disabled/Ill

Low Income/Poverty

Military

Homeless

Minorities

Students

Women

Men

The following categories best describe my interests:

Abused/Battered

Arts/Culture

Disabled/Ill

Disaster Victims

Education

Environment

Financial Stability

Health

Homeless

Law Offenders

Literacy

Poverty

Recreation

Rural

Safety Net Services

Sexual Assault

Substance Abuse

Teen Pregnancy

Transportation

Technology

Urban

Expectations

Please explain briefly what you hope to gain from the program:

What personal and professional goals do you expect to achieve through Leadership Berks?

What personal and professional goals do you expect to achieve through Blueprint for Leadership?

Tuition and Billing Information

Please select the appropriate item:

I am an employer-sponsored applicant. Please bill my employer.

I am an individual applicant sponsored by an organization other than my employer. Please bill my sponsoring organization.

I am an individual or employee of a non-profit organization interested in receiving a scholarship. (See scholarship section.)

Party responsible for tuition payment:

Name:

Title:

Address Line 1:

Address Line 2:

City:

State:

Zip Code:

Phone:

Email:

Scholarships

A limited number of partial scholarships are available for representatives of nonprofits or self-supported individuals. Scholarships are issued in accordance with funds available and there are no guarantees. If you would like to apply for a scholarship, please indicate the dollar amount needed (up to $450 for BFL and up to $1,500 for LB) along with an explanation of the need and why you wish to participate in the program.

Amount requested:

Please explain the need for the scholarship, what the community means to you and how you plan to participate in fostering positive change.

Or upload a document explaining the same.

Choose File

Scholarship recipients will be notified in writing along with full payment details.

Applicant/Employer/Sponsor Work Release & Support

I and my employer, sponsor, or supervisor fully support my participation in the program including release from work to attend sessions, meetings or events related to the program in whole or in part, without penalty. I, my employer, sponsor or supervisor agrees to meet all program expectations and requirements associated with participation including, but not limited to: attendance at weekly class sessions, Board/Committee observation and to fulfill all requirements associated with the terms of my placement with a voluntary community position for a minimum of one year as required after program completion.

Upon acceptance into the program, Blueprint for Leadership reserves the right to dismiss any person who fails to comply with participation guidelines or who fails to meet program requirements or expectations in or out of the classroom. Any person dismissed from the program, or their sponsor, will not be eligible for a tuition refund of any kind.

EMPLOYER commits to: Financial Support and Time Support

Approving Officer Name and Title:

Approving Officer Signature:

Date:

SPONSORING ORGANIZATION commits to: Financial Support and Time Support

Approving Officer Name and Title:

Approving Officer Signature:

Date:

Participant's Commitment Form & Media Release

If accepted into the program, I understand the commitment I am making to the Leadership Berks program.

Attendance at the mandatory 2-day opening retreat and all scheduled monthly sessions is important. I understand the time commitment required of me as a participant. If selected, I commit to attend all monthly sessions and I fully understand that should I miss more than two sessions, for whatever reason, I may be dismissed from the program with no portion of my tuition refunded. I will make necessary arrangements to be at sessions on time and remain all day at the sessions.
I will attend Graduation (June).
I understand that I am required to work on and complete a group project. I will fully participate in this project.
I am willing to devote my time and energy to the sessions, my project and the program, as a whole.
I will serve in a community leadership role/position with a Berks County nonprofit.
I understand that successful follow-through of these commitments is dependent upon completion of the program.
I, the undersigned, grant Leadership Berks/United Way of Berks County permission to use my story/interview and/or my photographs, video recordings, digital images, and the like, to use, but not limited to, print, digital and promotional materials and/or advertising materials. I acknowledge I will not receive any compensation for the use of my story/interview, pictures, images or recordings. Further, I grant all rights, title and interest to the finished pictures, negatives, reproductions and copies of the original prints and negatives and videos, including the right to transfer and exhibit the negatives, original prints, or copies and facsimiles thereof.

I understand the value of my acceptance and why my commitment, as well as that of my fellow classmates, is of great significance. My signature indicates I understand the above commitments and agree to uphold them to the best of my ability.

If accepted into the program, I understand the commitment I am making to the Blueprint for Leadership Program. Attendance and participation are mandatory. If selected, I commit to attend 6 sessions, one per week on Wednesday with specific details outlined in the course material. I understand that if I should miss more than two sessions, for whatever reason, I may be dismissed from the program with no portion of my tuition refunded. I will make necessary arrangements to be at sessions on time and remain all day at each session. I will attend graduation on June 8. I will serve in a community leadership role/position with a Berks County nonprofit. I understand ?. Blueprint for Leadership/ United Way of Berks County (continue normal release information already included).

Applicant Signature:

Date:

Items marked with an asterisk(*) are required

The official registration and financial information of the United Way of Berks County (UWBC) may be obtained from the Pennsylvania Department of State by calling toll free 800-732-0999. Registration does not imply endorsement.

Please note: If you select Payroll Deduction and submit your voluntary pledge to United Way of Berks County, you authorize your employer to make the one-time or recurring deduction from your pay as noted. Learn more about your pledge.

Your privacy is important to us. To learn how we will use your personal information, please read our Privacy Policy

United Way of Berks County | 25 N. 2nd Street, Suite 101 | 610-685-4550 | unitedway@uwberks.org

Berks United for Better

Leadership United Application

Personal Information

Program Applying For

Sponsoring Organization

Emergency Contact Information

Community Placement Requirement

Volunteer Interest

Expectations

Tuition and Billing Information

Scholarships

Applicant/Employer/Sponsor Work Release & Support

Participant's Commitment Form & Media Release