LEADership Civitan Region Certification Form

"*" indicates required fields

Name of Person Completing Form*

Email*

Region*

Name of LEADership Civitan Applicant*

Applicant Endorsement

In addition to the information provided by the applicant's home club, do you have any thoughts or information to share related to this applicant's candidacy for LEADership Civitan?

On behalf of the Leadership Council of my Civitan region, I (person named as completing this form) hereby endorse this applicant as a participant in LEADership Civitan:*

Yes

Other

Financial Commitment of Region

Has your region elected to sponsor some or all of the tuition for this applicant to participate?*

Yes

Other

LEADership Civitan is a two year intensive program with a total tuition fee of $2,400 per applicant. The fee may be paid in one lump sum or two payments of $1,200 over the 2 year term. This fee may be paid personally by the applicant, sponsored by the club, sponsored by the region, or a combination of the three. Payment due July 15th, 2025.

If your region has agreed to sponsor some or all of the tuition fee, please detail how payment will be completed for the applicant:

For example: Region will sponsor 100%, or region will sponsor 50%/club will sponsor 50%, or applicant will personally pay 75%/region will sponsor 25%