First Name *

Last Name *

Phone *

Phone *

Cell Number 

Email *

Do you live in Cushing? If so, How many Years? *

Do you Work in the Cushing Area? *

Yes

No

Do you expect to stay in Cushing for many years? *

Yes

No

If you do not reside in Cushing, Which surrounding Community do you live in? *

How often do you work/visit/shop in Cushing (per month)? *

EMPLOYMENT INFORMATION: Present Employer: *

Address Line 1 *

Address of Employer Business: 

Job Type *

Occupation:

Temporary

Part-time

Full-Time

Contract

Internship

Seasonal

Volunteer

Specific Job Title:

What do you consider your most significant career-related achievement? *

300 characters or less: 

Activities: *

Please list any volunteering you may do in the Cushing area, along with the Non-Profit Organization(s) you volunteer for: 

If none, please type in "None"

Civic, Religious, and Professional Organizations: *

Please list Civic, Religious, and Professional Organizations of which you are or have been a Member of: 

If none, please type in "None" or "N/A"

GENERAL INFORMATION: *

The goal of LEADERSHIP CUSHING is to identify, educate and develop potential leaders for our community by introducing LC participants to several different areas that help to make Cushing the community it is.  With this in mind, briefly explain why you wish to participate in LEADERSHIP CUSHING and what you expect to receive from the class:  

APPLICANT'S COMMITMENT: *

I (applicant) understand that completion of this application does not insure my acceptance in the class.  I understand that the Orientation is mandatory and that I am required to attend at least Ten (10) of the Twelve (12) sessions to be eligible to graduate from LEADERSHIP CUSHING 2024 (exceptions reviewed by Chamber President & CEO Tracy Caulfield).  I understand the purpose of the program, and if selected, will devote time to complete the program.  If appropriate, I have obtained the approval and consent of my employer and/or school to participate in LEADERSHIP CUSHING 2024.  I understand that I am accepting responsibility for community involvement in the future.  I understand these commitments and agree to be bound by them in signing this application.  

Please type Name and date: 

EMPLOYER'S COMMITMENT: *

I (Employer) understand the time commitement for my employee (or for this particular student in our school) and agree to allow this employee/student to devote the time necessary to be an active member of LEADERSHIP CUSHING 2024, if selected.  

Please type Employer's Name below and type date that Employer agreed: 

Would you like to apply for a tuition scholarship?

Potential Tuition Scholarships are for Member Partner businesses/nonprofits of the Cushing Chamber; if your business is a Member, you are able to submit your application for a scholarship.  Please click Yes below to be entered for one potential tuition scholarship.  Announcements of scholarship availability will be made to all who have applied for one by March 1, 2025.