Class of 2025 LSV Application

Before Applying

This application, available online (below) does not have a “SAVE” feature, and must be completed in your first attempt. Please do not start this application unless you have at least 60 minutes to provide your responses.

Thank you for your interest in applying for Leadership Susquehanna Valley! As more than 700 of our alumni can attest, this program will provide you with tools to be a more effective leader and to have a greater impact on your community.

Tuition Fee

$2,000.00
Scholarships are available for non-profits, small businesses, and self-pay candidates.

All expenses, including speakers, room rental, equipment fees and meals are included in the tuition fee.
Participants are responsible for their own travel expenses.

Deadlines

June 7, 2024 | All completed applications due to Leadership Susquehanna Valley.
July 12, 2024 | Selections Committee will notify candidate of application status.
August 2, 2024 | Tuition payment due in full for all accepted LSV program participants.

Section 1: Certification

Please read and confirm below your agreement with the policies and participation requirements of Leadership Susquehanna Valley.

1. I am at least 21 years of age.

2. I understand and agree to abide by the LSV Attendance Policy which states "All participants must attend the class orientation, class retreat, no less than seven (7) of the eight (8) program days, and the LSV Guy Temple Award Breakfast to be eligible for graduation."

3. I agree to the LSV Confidentiality Policy, which states: "I will deem confidential all information discussed by fellow class participants during the program day, so as to protect against identification, exploitation, and embarrassment. I will deem confidential the information disclosed to me by non-profit organizations and their boards of directors as I work on their behalf through the program. I agree to maintain the integrity of the Leadership Susquehanna Valley program and to recognize its trademarked format, schedule, and program materials. Finally, I agree to keep confidential the presentations and programs offered by LSV consultants and presenters, unless otherwise authorized by the presenter."

4. I understand that scholarship opportunities exist that may help applicants to cover the tuition fee. These scholarship opportunities each require a separate scholarship application, all of which are available on the LSV website.

5. I have read, understand and agree to abide by the Leadership Susquehanna Valley No-Refund Policy, which states: "Upon acceptance into the program and subsequent invoicing, tuition payment will be due in full within 30 days of the invoice and prior to the program year. All such payments are final, with no refunds or cancellations. If a paid participant opts out of the program prior to the Retreat, then the payee may offer a replacement candidate for approval by the LSV Board of Directors prior to the Retreat. If a candidates opts out of the program after the Retreat, all scholarship funds are forfeited to Leadership Susquehanna Valley, and the applicant is ineligible to apply for scholarships in the following year. No program vacancy may be filled after the Retreat."

6. I understand that I will be responsible to submit additional documentation, including a Photo-Waiver, Medical Form, and Dietary Restrictions Form prior to participating in the LSV Retreat.

Certification Confirmation

I certify that I understand and agree to the six (6) statements listed above, i.e. the LSV age requirement, LSV Attendance Policy, LSV Confidentiality Policy, the Statement on Scholarship Availability, the No-Refund Policy, and the requirement to submit additional documentation upon acceptance into the program.

Scholarship Assistance

I require full or partial scholarship assistance to pay for my tuition fee.

Authorized Company/Organization Representative

Please confirm the first and last name of the person granting this applicant's attendance and payment authorization.

First Name

Last Name

Section 2: Contact Information

Applicant Name

First Name

Last Name

Preferred Name

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth

YYYY

Cell Phone

(###)

###

####

Work Phone (Direct Line)

(###)

###

####

Email Address (Preferred)

Secondary Email

If you are concerned that your first email address might block vital communications regarding LSV, please provide a secondary email address here.

How did you hear about Leadership Susquehanna Valley?

Please indicate the name of the individual or organization through whom you learned of LSV.

What is your relationship to this person/organization?

Section 3: Employment Information

Present Employer (Company Name)

Employer Contact Name

Please indicate the information for the individual with whom you will be discussing your professional development during the LSV program year. (Director supervisor, mentor, or other)

First Name

Last Name

Employer Email Address

Employer Phone

(###)

###

####

Employer Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Employment Start Date

YYYY

Present Position

Education

List high school, college(s), business or trade schools, continuing education and other specialized training. Include name of school, city, state, dates attended, major, and degree.

Section 5: Background Information

Briefly describe your present job responsibilities and activities.

What do you consider your most significant contribution or achievement related to your work?

Please list business/professional affiliations in which you have been active.

Which one of the following categories best describes your present position? (Social Services, Government, Labor, Religion, Business/Industry, Media, Education, Law, Cultural, Medical, Technology, Other)?

Community or State Involvement

Please list in order of importance to you – community, civic, professional, religious, social or other activities. Note how much time each month you commit to these activities. Briefly state any contributions or achievements in these activities which you consider significant, and explain your role in the accomplishments.

Have you been as active in community, civic, or state affairs as you would like to be? If “No”, what has been the major barrier and what conditions have changed that enable you to envision involvement in the community?

What kinds of community or state boards, committees, or groups would you like to serve in the future?

General

Explain what you hope to gain from your Leadership Susquehanna Valley Experience.

Please explain what you hope to contribute to the program.

Where do you see yourself, with regard to community engagement, five years from now?

Please provide any additional information which you believe would assist the Selection Committee in assessing your qualifications.