2010 City of Winston-Salem University (CWSU) Application

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IMPORTANT DATES:
Deadline for Submission of Application: December 31, 2009 at 5:00 p.m.
Class Member Selection and Notification: January 14, 2010
Program Begins: January 28, 2010 at 6:00 p.m.

More information: (336)727-7360 or eddiejm@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

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:
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 the community?

Have you ever attended a government meeting? Why?

Class Requirements:

»Attend 9 out of 11 classes
»Attend at least one City Council meeting
»Ride a city bus route

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.