LEADership Civitan Club Certification Form "*" indicates required fields Name of Person Completing Form*Email* Civitan Club*Club Office*Name of LEADership Civitan Applicant*Applicant EndorsementIs the applicant considered a member-in-good-standing of your club?*Including current on financial obligations to the club Yes No Has the applicant participated in at least one club activity in the last year?* Yes No In what ways has the applicant actively contributed to your Civitan club?* Held a leadership position Regularly attends meetings and events Leads or volunteers at service projects Helps with club growth or outreach Represents the club at regional/international events On a scale of 1-5, how would you rate the applicant's commitment to the mission of Civitan?*1 = poor, 5 = excellent12345On a scale of 1-5, how would you rate the applicant's willingness to grow as a leader?*1 = poor, 5 = excellent12345On a scale of 1-5, how would you rate the applicant's reliability and follow-through?*1 = poor, 5 = excellent12345• Do you foresee this applicant taking on greater leadership roles at the club, regional, or international level in the future?* Yes No Other Financial CommitmentHas your Civitan club elected to sponsor some or all of the cost for this applicant to participate?* Yes No Other 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. If your club has agreed to sponsor some or all of this cost, please detail how payment will be completed for the applicant: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 EndorsementOn 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:* Yes No Other Do you have any additional thoughts or information to share related to this applicant's candidacy for LEADership Civitan?
