Birth & Breastfeeding Leadership Institute Application

Birth & Breastfeeding Leadership Institute Application
Thank you for your interest in applying to the Birth & Breastfeeding Leadership Institite. For more information about the application and interview process, please see the Frequently Asked Questions.
Personal Information
Name*

First NameLast Name
Credentials
(Ex: MD, MPH, MS)
Organization*
Title*
Phone Number*
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Email*
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Address*

Street Address

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References

Please provide contact information for 2-3 professional or community references.
Reference 1
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Title*
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Email*
example@example.com
Relationship*
Reference 2
Name*

First NameLast Name
Title*
Phone Number*
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Email*
example@example.com
Relationship*
Reference 3
Name

First NameLast Name
Title
Phone Number
Please enter a valid phone number.
Email
example@example.com
Relationship

Application Questions
Instructions: See the FAQ. Answer the following questions. A maximum of four pages, single-spaced, and 11 point font is allowed. Upload attachments.

Note: We respect the fact that writing may not be the only form of self-expression and as such you may also submit up to 2 optional supplemental materials using your own creativity (ex: podcast, short video, art, portfolio, etc).
1. Why are you interested in this leadership Institute?

2. Personally and professionally, what will you contribute to the leadership Institute?

3. Would you characterize your leadership experience as emerging, evolving or
established? What evidence do you present that demonstrates this? Refer to the leadership definitions below.

4. What is your “why”? In other words, what wakes you up in the morning and what keeps you up at night?

5. What is your theme song?

6. Describe what you have done in the past five to seven years as it relates to maternal child health equity that would qualify you to be selected.

7. Who are the people who make up your professional and personal networks? How do you engage with these networks?

8. In what ways does your work display your commitment to health equity?

9. Are you able to gain support from your immediate supervisor to commit to this journey? If you prefer not to get support, please explain why.
Leadership Definitions

Instructions: Integrate the following Guiding Principles with the detail of the Leadership Matrix to self-assess your community leadership experience at the intersection of racial equity and maternal-child-health. State if you are an emerging, evolving or established leader.

Guiding Principles

Racial equity/justice - Demonstrate a history of working towards more favorable Black birth and breastfeeding outcomes by influencing changes in attitudes, practices, and policies.
Community-centered approach - Demonstrate a history of amplifying the community voice and lived experiences of Black pregnant and breastfeeding persons.

Leadership Matrix

	EMERGING	EVOLVING	ESTABLISHED
Initiative	Ability to follow through on a plan but may require support/guidance	Ability to follow through on a plan with minimal to no direction	Ability to develop and follow through on a plan with no direction
Team Effort	Ability to work collaboratively and provide valuable input and suggestions	Ability to effectively lead collaborative teams and provide significant contributions	Ability to effectively build and lead collaborative teams; and strategically carry out an action plan while guiding and directing others
Obtaining Goals	Ability to work towards preset objectives and goals	Ability to develop and work toward objectives and goals	Ability to ideate, lead and execute ideas/projects to achieve goals and objectives

Payment
How do you intend to pay the leadership institute development fee? (Click all that apply)*

Self payment (full or payment plan)Employer payment (full or partial)NICHQ/T&A Healthy Start Grantee*
I understand that I must complete the scholarship application to be considered for a limited scholarship opportunity? (See link below)

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Scholarship Application Link
This is a preview of the scholarship application. If you select 'yes' you will receive the link to complete the scholarship application.

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Application Questions*

Upload pdf or word document with completed application questions. A maximum of four pages, single-spaced, and 11 point font is allowed.
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Resume*

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Letter of Recommendation 1*

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Letter of Recommendation 2*

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Supplemental Materials (optional, max 2)

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Birth & Breastfeeding Leadership Institute Application

Personal Information

References

Application Questions

Leadership Definitions

Payment

Uploads