Instructions: Please complete each section below. Required fields are marked with an asterisk. Applications are due by 11:59 pm on July 17, 2021.

AFFILIATION

Cohort members are expected to participate fully in the entire program and attend 9 out of 10 required days to qualify for induction. Generally, participation requires one full day per month for 10 months and a modest amount of additional personal time working on a cohort community service project. Please look at the Schedule at a Glance below to determine if you can fully participate in the program. The delegation trip to Washington DC is optional. Members with perfect attendance will receive a complimentary lifetime membership.

I have read and understand the Cohort Commitment and Schedule at a Glance as explained above and am willing to honor that commitment.

Your supervisor or employer must understand your commitment of this leadership development and training program and agree to provide the applicant with the time away from the workplace to attend all scheduled activities.

COHORT DUES

Annual dues can be paid online, over the phone by voice or text at 602-833-0258, or by check to Graham County Chamber of Commerce, 1051 W Thatcher Boulevard, Safford, AZ 85546.

I understand that my participation in the Gila Valley Leadership program may expose me to above normal risks due to travel, touring of area agriculture, mining, and government facilities and participation in team building exercises and encounters with other natural and man-made hazards. I also understand that although Gila Valley Leadership (a leadership development program administered by the Graham County Chamber of Commerce) will take precautions to provide proper instruction and supervision, it is impossible to guarantee absolute safety. I also understand that I share the responsibility for safety during the program and I assume that responsibility. If at any time I feel uncomfortable with an activity, I can exercise my right to withhold participation. I have in place personal health insurance and am responsible for any medical expenses that may arise as a result of accidental injury during participation. I understand that parts of the program may be physically or emotionally demanding. I affirm that my health is good, and that I am not under a physician’s care for any undisclosed condition that bears upon my fitness to participate. I understand that each participant must assume the risk of physical injury that could result from any of the activities. I hereby release Gila Valley Leadership and the Graham County Chamber of Commerce, its staff members, board/committee members, volunteers, financial supporters, and general members from all liability for any injury to me from participation in the Gila Valley Leadership program. I understand that these terms shall serve as a release of liability for my heirs, executors, administrators, and all members of my family.

I understand that photos of my face and my name will appear on websites, press releases, news organizations, and newsletters, and I agree to release my image and name.