IGNITE LEADERSHIP ACADEMY
Application/Letter of Commitment
Please include: signed Letter of Commitment, Letter of Reference, Leadership Essay and Summary of Qualifications. The package must
be received by 5 p.m. on June 1, 2016.
Current Contact Data
Name______________________________________________________________________________________
Employer___________________________________________________________________________________
Position/Title________________________________________________________________________________
Email Address_______________________________________________________________________________
Business Mailing Address
Address____________________________________________________________________________________
City, State, Zip_______________________________________________________________________________
Phone_____________________________________________________________________________________
Home Mailing Address
Address____________________________________________________________________________________
City, State, Zip_______________________________________________________________________________
Phone_____________________________________________________________________________________
Business
Home
Preferred Mailing Address: (check one)
q
q
Sponsoring Organization’s Commitment:
If selected, the Applicant’s organization agrees to:
P Provide travel and lodging costs associated with the program.
P Allow adequate time to attend the four two-day sessions and for the completion of assignments that will
enhance the understanding and application of the content areas of each session.
P Allow the Fellow time to connect with his or her coach and actively participate in distance learning activities.
Signed:
______________________________________________
(Executive Director, CEO, Administrator or Supervisor)
Enrollee Commitment:
If selected, the participant agrees to:
P Attend each of the four two-day sessions – no exceptions unless a letter is written by the sponsoring
organization to LeadingAge New York.
P Complete assignments to enhance the understanding and application of the content areas.
P Connect monthly with the LeadingAge New York IGNITE Leadership Academy coaches to discuss
assignments, on-going development, and additional professional development opportunities.
P Actively participate in the LeadingAge New York IGNITE Leadership Academy conference calls with your
group and assigned coach.
P Remain employed with the LeadingAge New York member for the duration of the period.
Signed:
______________________________________________
(Applicant)