EmailMe Form - Leading4Life 2025 Application

2025 Application

Name *

First Last

Organization *

Organization Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Work Email *

Work Phone Number

### - ### - ####

Application Requirements

1. Please attach a letter of support from your organization for you to participate in the leadership fellowship program *

2. Please attach a current bio or resumé. *

3. Affirmatively respond to the following statements:

A. I/my organization is willing to pay for the tuition for this 12-month program(check one) *

$1200 base tuition fee

$900 base tuition fee (for providers serving fewer than 50 consumers)

I am requesting a reduction in tuition (note amount)

B. I am willing to commit the time necessary to gain the fullest experience from this leadership fellowship program *

Yes

No

C. Will you be able to provide a photo of yourself for promotional materials? *

Yes

No

D. We have a goal to increase the diversity of our emerging leaders in this program. Please check the box if you identify as: Black, indigenous, people of color and/or LGBTQ+

Yes

4. Please respond to the following questions (no more than a two-paragraph response for each question):

What do you hope to gain from your fellowship experience?: *

What could you bring to the group to enhance the overall experience for all the class participants ? *

Application Deadline is October 4, 2024