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2. Application Form

   Please fill out the following and click submit when compete. If you have questions, please call the Community Engagement Office at (575) 541-2100.

4. First Name*
5. Last Name*
7. Address*
9. City*
10. State*
11. Zip Code*
13. Phone Number*
15. Email Address*
17. What District do you live in?*

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19. How did you hear about the Neighborhood Leadership Academy?*
21. Do you need any accommodations for accessibility? If yes, please list. *
23. Are you a member of a neighborhood association?*
25. Why do you want to participate in this program?*
27. Describe your present and past volunteer experience in Las Cruces?*
29. What do you expect to learn from the Las Cruces Neighborhood Leadership Academy?*
31. Is the information you provided in this application true and accurate?*
33. How long have you been living in Las Cruces (years)?*
35. Gender*
    -- Select One --MaleFemalePrefer not to answer
36. Age*
37. Race/Ethnicity*
39. Media/Photo Release: Photographs/Video may be taken during the Neighborhood Leadership Academy. The City of Las Cruces may utilize these photos/video for brochures, presentations, social media or newsletters*

    1. I agree
41. Statement of Committment: The purpose of the Neighborhood Leadership Academy is to provide the right resources and information to improve constituents' knowledge in regards to the City of Las Cruces' functions.*

    1. I Commit to attend at least 7 out of the 10 sessions
43. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
45. Electronic Signature*
46. Date *
    Date
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48. 1. Receive an email copy of this form.
49. Email address

    This field is not part of the form submission.

50. Submit

* indicates a required field