NEW LeadershipTM New York Summer Institute, 2014

E-mail Application to Dr. Dina Refki, Director, Center for Women in Government & Civil Society at Drefki@albany,edu
NEW LeadershipTM New York 2014

APPLICATION

(Please type or print clearly)

Date: Click here to enter text.

  1. Full name: Click here to enter text.
  2. College/University name:Click here to enter text.
  3. Permanent street address:
  1. Campus address (if different than permanent):
  1. Home phone: Click here to enter text. Cell phone: Click here to enter text.
  2. E-mail address(Please note: this is the address we will use for notification purposes):

Please notify us immediately if you change your address or telephone number.

  1. Please list your academic major(s):
  1. Please list your academic minor(s), if applicable:
  1. Class year:Click here to enter text.
  1. GPA(Please note: You are required to submit copies of your transcript for verification):Click here to enter text.
  1. Academic areas of interest:Click here to enter text.
  1. Race (please select all that apply):

☐ American Indian or Alaska Native

☐ Asian

☐ Black or African American

☐ Hispanic/Latina

☐ Native Hawaiian or Pacific Islander

☐Other

Comment:

  1. Do you wish to identify as LGBTQ? ☐Yes ☐No

Comment:

  1. Do you wish to identify as having a physical or learning disability?

☐Physically disabled ☐ Learning disabled ☐ Other

Comment:

Essay (please limit your answers to 250 words):

  1. What about NLNY interests you? Why would you like to be selected to participate?
  1. Describe any political or community activities and/or organizations with which you have been involved and provide a description of your role.
  1. How do you hope the knowledge and tools gained through this experience will help you in the future?
  1. What do you see as the most crucial public policy issue affecting women today? Why is this important to you and what should be done?

For Applicants Interested in Applying for Mini Grant Funding

**Please note: Participants are given the opportunity to revise their mini grant award proposal prior to the final submission.

  • Tell us about your project idea. What do you want to change on your campus/in your community? Why? How did you come to this conclusion? How will this effort promote a solution to an issue affecting youth and positive youth development?

Click here to enter text.

  1. References

Provide the names, titles, phone numbers, and e-mail addresses for three references. (At least one reference must be an academic reference.)

Reference 1:

Click here to enter text.

Reference 2:

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Reference 3:

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  1. So that we can improve our program outreach, please tell us where you heard about NLNY.

Allsupporting documents should be sent to:

Dr. Dina Refki

Director

Center for Women in Government & Civil Society

Draper Hall 302

135 Western Avenue

Albany, NY 12222

For additional information, contact Dina Refki at and at 518.442.5127.

Thank you for applying toNEW LeadershipTM New York 2014!