2022 Quest Participant Application – Leadership Greater Hartford

Name:

First Last

Preferred Name:

For roster and name badge (if different):

Title:

Company/Organization:

Work Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Work Phone

Ext.

Work Email:

Home Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Home Email:

Preferred contact:

Home
Work

Who referred you to this program?

Describe your current employment position and responsibilities.

List any current affiliations and community involvement:

Board/Commission/Council/Association/Committee/Task-force/Membership, etc.:

What do you expect to gain from participating in this program?

Periodic reporting on demographics, along with other information, is provided to our funders to evaluate the impact of our programs in the communities we serve. Please kindly provide the following information:

Gender

Date of Birth:

Marital Status:

Married
Single
Divorced
Widowed

Race/Ethnicity:

Asian
Native American
African American
Caucasian
Hispanic
Other

Household Income:

Under $22,500
$22,500-$50,000
$50,000-$75,000
$75,000-$100,000
Over $100,000

*Please check one

Educational Background:

Attendance: Monthly program sessions are held via Zoom unless otherwise specified. In addition, participants are expected to work on a task force to plan and implement a project designed to build a stronger, more unified community. We estimate task force activities may require approximately six additional hours each month beyond the scheduled monthly sessions. Participants are expected to attend a minimum of 85% of the program sessions and 85% of the task force meetings. I have read and understand the responsibilities as described above:

My supervisor has approved my participation.*

Yes
No

Applicant Signature: