Leadership Medina County

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Signature Class
Application
Please complete the following form. This form, essays, and commitment form are due by April 30, 2025. When we receive this completed form and essays, our selection committee will contact you for an interview. Download essays and commitment form by clicking each link below: Essay Questions - Due April 30, 2025 Commitment Form - Due April 30, 2025
First Name *
Last Name *
Preferred Name
First and Last Name as it should appear on name badge *
First and Last Name and credentials as it should appear on certificate *
When is the best day/time and best number/email to contact you for an interview? *
Business Information
Company Name *
Business Category
Title *
Email *
Phone *
Address 1 *
Address 2
City *
State/Province *
Zip *
If you do not have a supervisor, please write n/a in the following fields.
Supervisor's Name *
Supervisor's Title *
Supervisor's Email *
Personal Information
Cell phone *
Home Address (Line 1) *
Home Address (Line 2)
Home City *
Home State *
Home Zip Code *
Which city, village or township in Medina County do you reside? *
Interests and Activities
Please list the names of organizations where you currently volunteer.
Education
Military Service
Select from the following interests. What are ways you would like to serve in the community? You may select more than one.
Interests *	Advocacy Agriculture Aging/Senior Services Animals Arts Children/Youth Civil rights Conservation/Environment Disabilities Economic Development Education Energy Event Planning Family Finance Foundations Government/Public Service Grant Writing Health History Housing Human Services/Social Services Law/Criminal Justice/Safety Literacy Mental Health Mentoring Media/Communications Policy Poverty Recreation/Sports Religion/Religious Organizations Strategic Planning Substance Abuse Technology Workforce Development Young Professionals Other
How did you hear about us?
How did you learn about Leadership Medina County? *
Is there someone we can thank for referring you to Leadership Medina County?
Policies
Class of 2026 Calendar Refund Policy Policies and Commitments If you understand, accept, and agree to the policies, terms, and conditions set forth above (and as linked), then type in your name and click on the “I Agree” button below to acknowledge your acceptance and agreement. By typing your name below, you understand that you are electronically signing this document and are agreeing to all of the policies, terms, and conditions set forth above. You further understand that Leadership Medina County will rely upon your electronic signature to the same extent as if you had signed this document in ink. If you do not understand or accept or agree to the policies, terms, and conditions set forth above, then Do Not click on the “I Agree” button and exit this site.
Applicant Signature *
*	I agree
Leadership Medina County does not sell, rent, release or trade personal information about our users and members to others without prior consent or a court order. We use safe, secure technology and other privacy protection programs to keep personal information secure. Leadership Medina County provides information as a public service. Links do not imply any endorsement of accuracy or quality of services.
Privacy Policy
Yes, I would like to receive communications from Leadership Medina County by email.
Yes, I would like to receive communications from Leadership Medina County by phone.
Yes, I would like to receive communications from Leadership Medina County by mail.
Yes, I would like to receive text messages from Leadership Medina County.
What's the best number for us to text you? *

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Signature Class

Application

Download essays and commitment form by clicking each link below:

Essay Questions - Due April 30, 2025

Commitment Form - Due April 30, 2025

Business Information

Personal Information

Interests and Activities

How did you hear about us?

Policies