Leadership Academy Application Form

PERSONAL INFORMATION
Your First Name Your Last Name Your Phone Number (include area code) Alternate Phone Number (include area code) Emergency Contact Name Emergency Contact Relation Emergency Contact Phone Number(include area code) Your Preferred Email Alternate Email Your Birthday Your Street Address City State ZIP Your Country

MORE ABOUT YOU
Please select the category that best describes your experience with disability. I am a person with a disability.I am a family member to a person with a disability.I work for a disability services organizationI am interested in supporting and advancing disability rights.Other Please select your top 3 interests from the categories below. TransportationEmploymentHealthcareHousingEducationLeadership SkillsPublic SpeakingCivil Engagement Are you Hispanic or Latino? YesNo How do you identify? American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Pacific IslanderWhite What is your highest level of education? High School / GEDSome CollegeCollege Graduate (Bachelors Degree)Masters DegreeI did not graduate from High School Name of High School Name of College Are you currently employed? YesNo If yes, list name of your employer Disability type PhysicalIntellectual / CognitiveInvisible DisabilitySensory (Vision / Hearing)Other If "Other" is selected, please describe Accommodation Requests

SUPPLEMENTAL DOCUMENTATION REQUIRED
LETTER OF INTENT: Accepted file types: doc, docx, pdf, jpg. Max File Size 10MB. Tell us about yourself. Why do you want to join the Leadership Academy? What is your experience with disability advocacy? What do you hope to gain from this experience? LETTER OF RECOMMENDATION: Accepted file types: doc, docx, pdf, jpg. Max File Size 10MB. If employed, your letter of recommendation must come from your employer. If unemployed, your letter of recommendation may come from an Agency or Community Leader.

EXPECTATIONS AND REQUIREMENTS
Personal Reference #1 First Name Last Name Phone Email Relationship to Applicant EmployerCo-WorkerPersonalOther If Other: Personal Reference #2 First Name Last Name Phone Email Relationship to Applicant EmployerCo-WorkerPersonalOther If Other: