AREA CODE                         PHONE NUMBER

                                        APT #/STREET #2
                         CITY                                   STATE                   ZIP

Each year, the Residence Life Director specifically designs a Leadership Training Program for students that are interested in serving in some type of leadership capacity on the Stevens Campus. Participants will break through barriers to effective team interaction, improve communication skills, and learn the benefits of unleashing their total capabilities. Students that complete the Leadership Training Program receive: 1) a Certificate of Completion; 2) a valuable addition to their resume; and 3) excellent training in people skills.

If you desire to attend the Leadership Training Program, check the "yes" box under 
number 2.

1. I would be interested in serving as a: (check all that apply)
   Residence Hall Council Representative (a dorm representative to aid in the expression 
           of resident student opinions
   Student Congress Representative

2. I would be willing to participate in the specially designed Leadership Training Program.
Yes          No

In order to participate in the Leadership Training, you will check into the residence halls on Wednesday, August 6, 2014 between the hours of 12:00 p.m. and 1:00 p.m. You will attend Leadership Training from Wednesday evening, August 6, 2014 through Thursday afternoon, August 7, 2014.

NOTE: As part of this program, you will interact with both second year and first year students 
that are, or will be, involved in various leadership positions on campus.

3. Would you be willing to serve as a student ambassador?
Yes          No

1. SCHOOL: Please list your educational courses, student government experiences, participation in peer counseling groups, SADD, or other service clubs or leadership groups in which you have participated:

2. WORK: Please list any paid or volunteer employment in which you worked with people in a helping relationship.

3. COMMUNITY: Please list any organizations or community service programs in which you have participated.

NOTE: It is not necessary to have been involved in any of the above in order to take part in our leadership program.)


Please list a brief statement as to why you would like to be involved in a student leadership program. Indicate the number of hours that you believe you could participate.


Are there any other service programs in which you might like to participate while a student at Stevens – either on campus or in the community?

Thank you for completing this questionnaire. If you have any questions pertaining to The Leadership Program or this survey, please contact Mr. Jason Kuntz at: