Application form

Leading Australian Resilient Communities - Intensive Leadership Program

1Applicant Details

2Applicant Details

3Accessibility Needs

4Education & Employment Details

5Community Impact

6Community Impact

7Consent

We are delighted you are interested in applying for our Leading Australian Resilient Communities Program. All applications are assessed by a selection panel, and you will be advised of the outcome of your application once the selection process has been completed.
During the selection process, we aim to make the Program cohort a diverse mix of backgrounds, industries, occupations, and experience. This is to ensure the cohort has a wide diversity of thought, which makes for a more rewarding experience for all participants.

WHEN APPLYING, PLEASE NOTE:
• All applications are confidential.
• All questions must be completed in full and the declaration must be signed.
• You can save and continue this form by clicking the save and continue button at the bottom of the page. A unique link will be sent to your email so you can return to your application form.
Which region do you live in?*
- Midwest Coastal
Do you feel you have capacity to commit to this Program ( see details below)*
The Program consists of 2 x 3 day Residentials ( dates can be found on our website). There will also be a Project that we estimate will require 10-15 hours over 3 months.
First Name*
Last Name*
Preferred Name
If this is different to your First Name
Company Name*
If you are currently not working or retired please just put N/A
Email*
Mobile
Alternative phone number

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Referee
Please provide details of a referee knowledgeable about you as a leader in your region – either your performance or your potential. As part of the selection process we may contact them to learn more about you.
Referee Full Name*
Please provide details of a Referee knowledgeable about you as a leader in your region – either your performance or your potential. As part of the selection process we may contact them to learn more about you.
First Last
What is the referee's relationship to you*
Referee’s Organisation/Business Name*
Referee’s Position Title*
Referee's Email*
Referee's Contact Number*
*
I confirm that the information provided in this application is true and correct
*
I confirm that I understand the time commitment required to participate in this Program
*
I agree to be contacted by Leadership WA
Your data is collected in compliance with our data collection and privacy policies which can be viewed at www.rural-leaders.org.au/policies/
By submitting this application, you grant Leadership WA your permission to share Program photography and videography across their social media channels, and the social media channels of affiliate partners included in the Building Resilient Regional Leaders Initiative (Pilot). Your consent also extends to traditional media including newspapers and collateral.
Name
This field is for validation purposes and should be left unchanged.

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