LeadDIVERSITY 2023 Application - Inclusive Communities

LeadDIVERSITY Application

General Information

Name(Required)

First Last

Pronouns(Required)

Preferred Name, if different

Date of Birth(Required)

Gender Identity(Required)

Other Personal Identity

Race(Required)

Faith/Spirituality(Required)

Home Address(Required)

Street Address City State ZIP Code

Phone(Required)

Email(Required)

Industry Type(Required)

Non-profit

Corporate

Healthcare

Education

Military

Government/Civic

Other

Job Title(Required)

Business/Organization Name(Required)

Work Address

Street Address City State ZIP Code

Work Phone(Required)

Work Email(Required)

How did you learn about LeadDIVERSITY?(Required)

Supervisor Information

Please provide Supervisor’s information. We highly recommend you inform your supervisor prior to applying for this program as you will need their consent to participate if selected.

My direct supervisor is aware of LeadDIVERSITY and supports my full participation in the program.

Yes

Not applicable

Supervisor Name(Required)

First Last

Supervisor Title

Supervisor Phone

Supervisor Email(Required)

Attachments and Essay Questions

Resume(Required)

Please attach a resume detailing your education, employment, community involvement or engagement, and any previous diversity training

Accepted file types: pdf, doc, docx, Max. file size: 64 MB.

Letter of Recommendation

Accepted file types: pdf, doc, docx, Max. file size: 64 MB.

You are welcome to provide a personal or professional letter of recommendation to support your application. A letter of recommendation is not required to apply.

Essay Question Attachments

Please answer the 4 questions below. You are welcome to submit your entries in written or video format. Written response can go in the boxes below or you may submit responses via an attachment and upload it here. Please limit written responses to 500 characters per question. If you choose to submit a video response. Please save it as a YouTube or Vimeo file upload a PDF or DOC with the link to the video file enclosed. Please submit only 1 video for all 4 answers. Please limit videos to no more than 8 minutes. DO NOT UPLOAD VIDEO FILE TO APPLICATION.

Accepted file types: pdf, doc, docx, Max. file size: 64 MB.

Question 1: Why do you want to be a part of LeadDIVERSITY?(Required)

Write your response in the box provided, if you are submitting answers as an attachment or a video, enter video or attachment response in the box.

Question 2: Share an example in your life or career that best demonstrates how you are collaborative.(Required)

Write your response in the box provided, if you are submitting answers as an attachment or a video, enter video or attachment response in the box.

Question 3: Share about something in your life or career that is most connected to your desire to create systemic change.(Required)

Write your response in the box provided, if you are submitting answers as an attachment or a video, enter video or attachment response in the box.

Question 4: Share about something in your life or career that exemplifies your community engagement.(Required)

Write your response in the box provided, if you are submitting answers as an attachment or a video, enter video or attachment response in the box.

I have submitted the following attachments

Essay Attachment

Resume

Letter of Recommendation

Emergency Information

Emergency Contact Name(Required)

First Last

Relationship(Required)

Emergency Contact Phone(Required)

Participation Consent & Agreements

In order to accomplish the program’s objectives, the full participation of each individual selected is necessary. Participants may miss no more than one of the scheduled program dates. Participation at each session requires attendance for the entire scheduled day. Missing more than one session will jeopardize participant’s eligibility for graduation.

Session Dates (unless otherwise noted sessions are from 8:30am – 4:30pm):
August 24 8:30am-11:30am – Meet and Greet
Session One – September 20
Session Two – October 11
Session Three – November 8
Session Four – December 13
Session Five – January 10
Session Six – February 21
Session Seven – March 13
Session Eight – April 10
Session Nine – May 8
Session Ten – May 16 8:30am – 1pm
Graduation – June 14 3pm -7pm

APPLICATIONS ARE DUE midnight June 12, 2023

Participant Agreement(Required)

I understand that submission of an application does not guarantee acceptance into the LeadDIVERSITY Cohort. I understand that this is a competitive application process and I am able to fulfill the time requirements.

I have read and understand the statement below.

Consent to contact supervisor(Required)

I authorize Inclusive Communities to contact the supervisor I have listed above.

Tuition for each participant in the LeadDIVERSITY Class of 2023/24 is $2,200. Applicants may be sponsored by their employer or may sponsor themselves, with agreement from their employer. A limited number of partial scholarships are available, based on financial need. If you are accepted into the LeadDIVERSITY Class of 2023/24, you and/or your employer will be invoiced accordingly. Payment is due prior to the August Meet & Greet. We do not want the cost to be prohibitive for your attendance, therefore, Inclusive Communities is willing to work with you to mitigate any barriers. Please email brittany@inclusive-communities.org if you need to discuss financial assistance for attending this program.

After reading the above information on tuition, please check all that apply(Required)

I will be sponsored by my employer

I will be partially sponsored by my employer

I will be self-sponsored

I am applying for a partial scholarship

Photo/Video Consent(Required)

If I am accepted as a member of the LeadDIVERSITY Class of 2023/2024, I give permission for my photo and/or video image to be used in any publicity materials for Inclusive Communities

Yes

Verification(Required)

I verify that the information provided in this application is complete and accurate to the best of my knowledge.

"*" indicates required fields

First Name

Last Name

Email*

Name

This field is for validation purposes and should be left unchanged.