Application Form

*Before you fill out this form, make sure the website address typed in has "www." at the beginning of the URL, otherwise it will ask you for a password.

Name:
Email:
Address:
City:
Preferred Telephone:
Alternate Telephone:
Profession/Industry:
Employer:
Office Location (City):
Civic Activities, Organizations

1. What issues should the city address or concern you the most?

2. What do you hope to gain from the Leadership Hermosa Beach program?

3. What are your main reasons for joining this program?

4. What skills do you think you could bring to Leadership Hermosa Beach?

5. How did you learn about Leadership Hermosa Beach?

Pledge of Time and Financial Commitment

In order to receive maximum benefit from Leadership Hermosa Beach's objectives, I pledge my full participation and commit to the following:

1) Attendance at the mandatory Leadership Hermosa Beach orientation day on Saturday, September 10th, from 9am to 6pm;

2) Attendance at no less than 8 of the 10 program classes (held on the 3rd Thursday of every month, from 6pm to 9pm, from September to June);

3) Dedication of time as needed to complete the class Community Service Project by graduation; and

4) Payment of the $250 program tuition by or on the Leadership Hermosa Beach orientation day.

Signature: Date: