Ellevate Louisiana Membership Scholarship Application Form

Name

First NameLast Name

Email

example@example.com

Cell Phone Number

Please enter a valid phone number.

Occupation/Title*

Business/Organization*

Industry*

Where did you learn about Ellevate Louisiana? *

In 3-5 sentences, please share your interest in joining Ellevate Louisiana.*

Why are you seeking financial assistance?*

Have you sourced other avenues to sponsor your membership costs? (i.e., personal mentor, employer, etc.)*

YesNo

What region of the state are you currently located?*

Political Party: As a cross-partisan organization, we value diversity and aim to have a balanced representation from multiple political parties. In order to maintain our cross-partisan stance, we kindly ask for members to share their political affiliations. This helps us ensure that our organization remains inclusive and respectful of various perspectives. *Please note that this information is confidential.**

Please share with us any leadership or community activities you have participated in. This can include religious, industry, or community activities or organizations. *

Identify any personal attributes, skills, or experiences that may be beneficial to Ellevate Louisiana.*

Scholarship recipients are required to attend one Ellevate LA event in person and serve on, and actively participate in, at least one Ellevate Policy Committee or Ad-Hoc committee for the duration of the scholarship period. Are you willing to make that commitment? Please make your committee selection(s) in the following questions below.*

YesNo

Identify which Ellevate Committee(s) you would be most interested in serving on. Please review our website for further information on our committees.*

Early Education & K-12 Policy CommitteeEnvironment & Infrastructure Policy CommitteeHealth & Wellness Policy CommitteeTaxation & Economic Development Policy CommitteeWorkforce & Higher Education Policy CommitteeMembership CommitteeEvents CommitteeFundraising & Development Committee

Please provide a reference.

Name: First Name   Last Name
Organization:Business Name
Email:   Email
Is your reference an Ellevate LA member?Yes or No*