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My Chesterfield Academy Application

2. * Indicates required fields

4. First Name:*

5. Last Name:*

7. Address:*

9. City:*

10. State:*

11. Zip Code:*

13. Email Address:*

14. Phone Number:*

16. Gender:*
    -- Select One --FemaleMaleNon-binary/third genderPrefer not to say

18. Country of Origin:*

20. Are you employed?*

    1. Yes
    2. No

22. If employed, give Employer Name:

24. Employer Address:

26. Job Title

27. Length of Employment

29. Is your employer aware that you would like to participate in My Chesterfield Academy?

    1. Yes
    2. No

31. Community Service and Engagement (please describe any leadership positions). Limit description to 200 words.*

33. Explain why you are interested in participating in My Chesterfield Academy, and what you hope to gain from the experience.*

35. List three concerns or issues that you think affect residents in Chesterfield County or our region:*

37. Please attach your resume or CV. (Size should be less than 2 MB. Allowed extension are: doc., docx., pdf, txt or csv)

39. Please include the name of three references, including relationship, their email and phone number.*

41. Please tell us how you heard about My Chesterfield Academy.*

43. Do you have other family members who are applying for this session of My Chesterfield Academy?*

    1. Yes
    2. No

45. If yes, please list name and relationship:

47. Commitment Contract*

    You must agree to all of the following terms to be considered for participation.

    1. I will attend at least 6 of the 7 My Chesterfield Academy classes.
    2. I will participate in My Chesterfield Academy honestly, thoughtfully and with an open mind.
    3. I will share what I learn at My Chesterfield Academy with friends, family and community members.
    4. I will stay connected with My Chesterfield Academy after graduation by participating in the My Chesterfield Academy Alumni Network.
    5. If employed, my employer has agreed to my participation in My Chesterfield Academy and has approved my taking the sessions on the dates scheduled.
    6. Participation is free. (Participants will be required to deposit a refundable $50 fee to cover meals and other expenses. This fee will be returned upon graduation.)
49. Acknowledgement*

    I acknowledge that video and still photos will be taken during the academy and may be used in county promotions.

    1. Yes
51. Please Initial that you agree to the commitment contract*

Leave This Blank:


53. 1. Receive an email copy of this form.
54. Email address

    This field is not part of the form submission.

55. Submit

* indicates a required field