Leaders for Geelong Program Application


To apply for the 2021/22 Leaders for Geelong program, please complete the application form below and upload your current CV and a supporting statement from your employer (unless self-nominating). A shortlisting process will then be undertaken before an interview. If you have any questions, please contact Vicki Strachan on victoria.strachan@committeeforgeelong.com.au or 03 5227 8075.

    Leaders for Geelong Program Application


    • To complete this application you will need to attach your CV and a supporting statement from your employer (unless self-nominating).
    • Applications close 23 March 2021. Applicants will be shortlisted and interviewed in March 2021.
    • Offers will be made by 31 March 2021.
    • The form must be completed in one sitting. You cannot save the form to complete later. We recommend completing the application in Word and then copying and pasting into the form.

    Contact Details

    First Name*
    Last Name*
    Preferred Name (for name tags)*
    Business Email*
    Personal Email*
    Contact Phone Details - Business*
    Contact Phone Details - Mobile*
    Personal Address (Street, Suburb, City, Postcode, State)*

    Organisation Contact Details

    Organisation - Name*
    Organisation - Current Job Title*
    Organisation - Date Commenced mm-yyyy*
    Manager Job Title*
    Manager Name (note N/A if not applicable)
    Manager Email (note N/A if not applicable)
    Manager Phone Number (type N/A if not applicable)

    Contact Details

    Business Address (PO BOX/Street, Suburb, City, Postcode, State)*
    Preferred Contact Address (Business / Private / Other)*
    If Other, enter Preferred Address (if applicable)

    Personal Details

    Dietary requirements - Yes / No* YesNo
    If Yes, Please enter comments
    Do you have access requirements (e.g. access, language, literacy, numeracy)?* YesNo
    If yes, how can we assist you?
    Do you identify as an Aboriginal or Torres Strait Islander YesNo
    Do you identify as a person with disability?
    Description of your cultural/ethnic background?
    Date of Birth (DD-MM-YYYY)*
    Emergency Contact Name*
    Emergency Contact Email Address*
    Emergency Contact Mobile Ph No*
    LinkedIn Address (if applicable)
    Twitter Handle (if applicable)
    Invoice Contact Details (who is responsible for payment)*
    Email Address for Invoice*
    Invoicing Phone Contact Details*
    Attach CV here*
    Max file size: 2MB and allowed file types: pdf,doc,docx,jpg,jpeg,png

    Employment / Experiences

    Please provide a brief description of your current role and responsibilities?*


    Provide details of any relevant development or leadership courses including units you have recently completed via employment*


    Please list in order of importance, up to five community, civic, professional, business, religious, social, sports or other organisations of which you are (or have been) a member in a volunteer capacity*
    If you have previously not had the time to become actively involved, what conditions have now changed that allows you to see involvment in the community in a leadership capacity?
    What kinds of volunteer/community activites would you like to pursue in the future?

    Leadership Development Questions

    What Personal Leadership Learnings do you hope to gain from the Leaders for Geelong Program? *
    What Organisational Leadership Learnings do you hope to gain from the Leaders for Geelong Program?*
    What Community-based Leadership Learnings do you hope to gain from the Leaders for Geelong Program?*
    How are you going to measure the success of your involvement in the Leaders for Geelong program?*
    How did you hear about the Leaders for Geelong program?* via Employervia Alumni/Current Participantvia Presentervia Speakervia Facebookvia Linkedinvia Printvia Media/Other
    Do you have any further comments?:

    Participant Agreement


    LfG 2021/2022 commences April 2021 and concludes June 2022. As a guide, the time commitment and attendance includes:

    • 2021 Opening Residential ( 2 days/1 night )
    • Day Seminars and Evening Workshops
    • Canberra Delegation ( 2 days/1 night )
    • Community Based Action Learning Project
    • Project Presentation Event
    • Closing Seminar & Lunch
    • Graduation Dinner
    • COVID-19

      Government COVID-19 restrictions may lead to last minute changes/cancellations of some events. This changes are unavoidable. We will do our best to reschedule seminars but cannot guarantee this.*



      Participants are required to maintain a minimum attendance of 80% across all core program events. Inability to meet the 80% attendance requirement may result in consultation with the participant’s employer and/or possible release from the program before completion date.*



      The fee for the 2021/2022 Leaders for Geelong Program is $6,700 +GST (not including the cost of return flight to Canberra). This fee may be paid by the participant or the employer and is payable on acceptance into the program.*


      Individuals or organisations with financial or economic barriers should not be discouraged from applying. Contact Victoria Strachan on 5227 8075 to discuss individual circumstances in confidence.

      Cancellation/withdrawal from the program

      All cancellations (and/or subsequent withdrawals from the program) must be advised in writing. Charges for cancellations and withdrawals will be applied, as stated below, to cover fixed cost commitments and administration fees. Cancellations received prior to the commencement of the program will incur a 10% cancellation fee. Please note that program places are non-transferrable.
      Notification of withdrawal within 3 months of the program commencement will incur a 50% cancellation fee. No refunds will apply after this point as places cannot be offered to other candidates.


      The Committee for Geelong are committed to protecting and respecting the privacy of its members, staff and participants by handling all personal information securely and with care in accordance with Australian privacy laws.

      Disclosure Statement

      Your personal information is collected on this form for the purpose of your participation in the Leaders for Geelong Program. The Company may disclose your personal information kept on our database to third party organisations for the purpose of functions, events, programs and initiatives of the Company. If you would like to access your personal information held by us, or would like to withdraw your consent to share personal information at anytime, please contact the Leadership Portfolio Manager of the Committee for Geelong.

      Declaration and Participant Agreement

      I declare that the information supplied by me is true and correct. I understand the goals of the program and the time commitment required of a participant in the Leaders for Geelong program. If selected for the program:

      • I will devote the required time to attendance and personal involvement;
      • I agree that any information and photographs throughout the program may be used for promotion - including the Committee for Geelong leadership programs and associated websites;
      • I understand that Government COVID restrictions may result in rescheduledm, altered delivery method and/or cancelled events.
      • I consent to have my email address shared amongst participants
      • I understand that as a Leaders for Geelong alumni, beyond the program, I commit to increased involvement and leadership in the community.
      • I confirm that I understand and agree to the conditions outlined.
      Applicant name*
      Applicant signature (Sign below with your mouse)*
      Date: (dd-mm-yyyy)*

      Employer Agreement/Responsibility (or if self-nominating)

      The candidate has my full support to participate in the next Leaders for Geelong program. I am aware of the time commitment, organisational and financial contribution.

      Please attached signed supporting statement from employer on company letterhead.
      Max file size: 2MB and allowed file types: pdf,doc,docx,jpg,jpeg,png

    Committee For Geelong

    Level 1 Sally Walker Building,
    1 Gheringhap Street,
    Geelong, Victoria, 3220

    +61 3 5227 8075

    9:00am – 5:00pm
    Monday to Friday

    The Committee for Geelong acknowledges Aboriginal and Torres Strait Islander people as Australia's First Nations people and the Traditional Custodians of the land and waterways. We pay our respects to the local Wadawurrung people of this land, their Elders past, present and emerging.