2018 Leadership Institute

APPLICATION and Essay Questions

APPLICANT INFORMATION (*Asterisked items are required

Applicant Name: [PRE-POPULATED]

*Home address:

*City, State & Zip Code:

Employer (if applicable):

Title (if applicable):

Work Address (if applicable):

Room, Suite, or Floor:

City, State & Zip Code:

Is your employer aware of your application to this program?:

*Applicant Preferred Telephone Number:

*Applicant Preferred Email Address:

*LinkedIn URL:

Personal Website:

*What is the best way to contact Applicant?

Email Phone LinkedIn

  1. Please list current volunteer or civic positions (include the title/role, name of the organization, and date of start):
  1. *Regarding future civic engagement, please select your first, second, and third primary interest areas from the following list: Arts, Business, Community Inclusion, Culture, Disability, Civil Rights, Education, Employment, Environment, Government, Healthcare, Philanthropy, Policy, Sports & Recreation, Technology, Transportation, Urban Planning,Other (enter):

First:

Second:

Third:

  1. Self-Disclosure Form

The following survey will not influence a decision regarding placement into the program. This information will be used to help this program measure its success in attracting diverse applicants. Each option includes the opportunity to opt to not disclose information.

GenderSexual Orientation

____ Male___ Gay

____ Female___ Lesbian

____ Transgender Male___ Bisexual

____Transgender Female___ Queer

____Opt not to disclose___ Heterosexual

Self-Identified______Opt not to disclose

Self-Identified______

Disability

___ Physical

___ Blind/Low visionVeteran

___ Deaf/Hard of hearing___ Yes ___ No ___ Opt not to disclose

___ Intellectual/Developmental

___ Mental Health

___ Opt not to disclose

___ Other

Race

___ Hispanic or Latino___ Black or African American

___ Asian___ American Indian

___ Alaskan Native___ White/Caucasian

___Hawaiian Islander, Pacific Islander ___ Two or more races

___ 0ther___ Opt not to disclose

ACCOMMODATIONS

Disability accommodation conversations for retreat and program events will take place once candidate is admitted into the program.

*ESSAY QUESTIONS

Please answer the following questions:

  1. *What is one challenge facing your community you are passionate about changing and how do you see participation in the Leadership Institute as a step toward making this change? [Approximately 250 words]
  1. *Describe a challenging experience you have had around your identity. How were you able to address it? Was it effective? Why or why not?[Approximately 250 words]
  1. *Discuss relevant leadership experiences, and how participating in the Leadership Institute in 2018 will help advance your goals.[Approximately 250 words]

*RESUME/CV

*Attach a CV or Resume to complete this portion of your application:

Please make sure you have includeda resume or CV including education, work, and volunteer experience.