• PERSONAL DATA

  One of the objectives of the LeadDIVERSITY program is to represent a cross section of the entire community. Please assist us by completing the following (please print):
• Name*
  First Last
• Preferred version of name (if different from above)
• Date of Birth*
  MM slash DD slash YYYY
• Place of Birth*
• Gender Identity*
• Other Personal Identity*
• Race*
• Faith/Spirituality*
• Home Address*
  Street Address City ZIP Code
• Home Phone*
• Home E-mail*
• Industry Type*
  • Non-Profit
  • Corporation
  • Healthcare
  • Education
  • Military
  • Government/Civic
  • Other
• Other
• Title*
• Business/Organizational Name*
  Business Name City ZIP Code
• Business Phone*
• Business Email*
• How did you hear about LeadDIVERSITY?*

• PARTICIPATION

  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.
• • I understand that this is a competitive application process and I am able to fulfill this time requirement.
• Please sign your name to indicate you have read this section and agree to meet the requirements*
• IMPORTANT - PLEASE HOLD THE FOLLOWING DATES ON YOUR CALENDAR:
  August 13, 2021 - Meet and Greet
• September 8, 2021
  
• October 13, 2021
  February 9, 2022
• November 10, 2021
  March 9, 2022
• December 8, 2021
  April 13, 2022
• January 12, 2022
  May 11, 2022
  

• APPLICATIONS ARE DUE FRIDAY, JUNE 18, 2021

• REFERENCES/LETTER OF RECOMMENDATION

  Please submit two references who would be able to comment on your ability to make a significant contribution in your community on diversity issues.
• Name 1*
• Relationship*
• Phone Number*
• Email*
• Name 2*
• Relationship*
• Phone Number*
• Email*
• You may also choose to submit one letter of recommendation from your employer or a community agency. This letter is optional.
  • I have enclosed a letter of recommendation.
  • I am not submitting a letter of recommendation.
• Letter of Recommendation
  Accepted file types: jpg, gif, png, pdf, Max. file size: 16 MB.

• SUPERVISOR INFORMATION

• Supervisor*
  • My direct supervisor is aware of LeadDIVERSITY and supports my full participation in the program. (Please attach a brief letter from your supervisor indicating their support of your participation and their knowledge of the attendance requirements.)
  • Not Applicable
• Brief Letter
  Accepted file types: jpg, gif, png, pdf, Max. file size: 16 MB.
• Name of Supervisor
• Title
• Business Address
  Street Address City ZIP Code
• Phone
• Email

• TUITION & PAYMENT

  • Tuition for each participant in the LeadDIVERSITY Class of 2021/22 is $1,750.
  • 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 2021/22, you and/or your employer will be invoiced accordingly.
  • Payment is due immediately upon acceptance to the program.
• After reading the above statement regarding tuition and commitment, please check all that apply:
  • I will be sponsored by my employer.
  • I will be self-sponsored.
  • I am applying for a partial scholarship

• ESSAY AND RESUME

• Please attach a brief essay explaining why you believe your participation in LeadDIVERSITY would be valuable to you as an agent of change in your community and (if applicable) your employer as an opportunity to build influence and build collaboration.*
  Accepted file types: jpg, gif, png, pdf, Max. file size: 16 MB.
• Please attach a resume detailing your education, employment, community involvement or engagement, and any previous diversity training.*
  Accepted file types: jpg, gif, png, pdf, Max. file size: 16 MB.

• APPLICATION REVIEW

• The application deadline is Friday, June 18, 2021

  Your participation status will be confirmed via letter or e-mail by July 23, 2021.

• ATTACHMENTS

• Attached Files*
  • Letter of Recommendation
  • Participation Note from Supervisor
  • Resume
  • Essay
• If I am accepted as a member of the LeadDIVERSITY Class of 2021/2022, I give permission for my photo and/or video image to be used in any publicity materials for Inclusive Communities*
  • Yes
  • No
• I verify that the information in this application is complete and accurate to the best of my knowledge.
• Signature*
• Date*
  MM slash DD slash YYYY

• EMERGENCY CONTACT INFORMATION

• Name*
• Phone*
• Relationship*
• Email
  This field is for validation purposes and should be left unchanged.

Application Save and Continue Later

Applications for Cohort #3 will be accepted between May 7 and June 18, 2021.

If you have any questions please email Tena@inclusive-communities.org.

Applicants should provide the following:

• Completed Application Form
• Up to 2 References (people who can speak to your interest in inclusion, diversity and equity)
• Participation note from Supervisor
• Resume
• Essay

Essay and Resume Info

• Write a brief, no more than 2 page, essay explaining why you believe your participation in LeadDIVERSITY would be valuable to you as an agent of change in your community and (if applicable) your employer as a person of influence and opportunity for collaboration
• Resume should detail in addition to your education and employment, your community involvement/engagement and any previous diversity and inclusion training.