LEADership Civitan Club Certification Form

"*" indicates required fields

Applicant Endorsement

Is the applicant considered a member-in-good-standing of your club?*
Including current on financial obligations to the club
Has the applicant participated in at least one club activity in the last year?*
In what ways has the applicant actively contributed to your Civitan club?*
1 = poor, 5 = excellent
1 = poor, 5 = excellent
1 = poor, 5 = excellent
• Do you foresee this applicant taking on greater leadership roles at the club, regional, or international level in the future?*

Financial Commitment

Has your Civitan club elected to sponsor some or all of the cost for this applicant to participate?*

LEADership Civitan is a two year intensive program with a total registration cost 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 June 30th, 2025.
For example: Club will sponsor 100%, or club will sponsor 50%/region will sponsor 50%, or applicant will personally pay 75%/club will sponsor 25%

Final Endorsement

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