2012 City of Winston-Salem University (CWSU) Application

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IMPORTANT DATES:
Deadline for Submission of Application EXTENDED: December 30, 2011, at 5:00 p.m.
Class Member Selection Notification: January 13, 2012
Program Begins: February 2, 2012, at 6:00 p.m.

More information: (336)747-7360 or susans@cityofws.org.

Applicants will be selected for the City of Winston-Salem University using three criteria:

Leadership Potential
Reasons for Involvement
Diversity and Residency Location
Must not have a criminal record (a background check will be conducted)

Please note: City of Winston-Salem residents receive first priority, then Forsyth County residents.

All questions must be answered

Name:
Address:
City, State, Zip:
Home Phone:	xxx-xxx-xxxx
Work Phone:	xxx-xxx-xxxx
Employer:
Current Position:
E-mail Address:
Race:
Gender:
Date of Birth:	mm/dd/year
NC Driver's License #:
Highest level of education obtained:
Emergency Contact Name:
Emergency Contact Phone Number:	xxx-xxx-xxxx

Special needs accommodation in order for you to participate in the program i.e. dietary,
physical:

Community Involvement/Professional Activities:

Why do you wish to be enrolled in CWSU?:

What is your leadership potential in the community?

Upon completion of the program, how do you hope to influence your community?

Have you ever attended a government meeting? Why?

Class Requirements:

Attend 10 out of 12 classes (cannot miss more than 2 classes)
Attend at least one City Council or Council Committee meeting
Complete a ride along with the Winston-Salem Police Department
Shadow a CityLink agent
Complete a budget exercise
Optional - Complete a ride along with the Winston-Salem Fire Department

I certify that every statement is correct and agree to meet all class requirements, if accepted into the program. Failure to meet the requirements could result in disqualification from attending any future CWSU programs.