Personal Information:
Salutation
*
None
Mr.
Mrs.
Ms.
First Name
*
Middle Initial
Last Name
*
Suffix
None
Jr.
Sr.
Phd.
EdD.
Other
Nickname/Preferred Name
*
Phonetic Pronunciation of Name
*
Preferred Pronouns
*
he/him/his
he/him/his
she/her
they/them/theirs
ze/zir/zirs
ze/his/hirz
Company/Agency
Job Title
What other LM programs (if any) have you participated in?
Emerging Leaders
CORE
Senior Leadership Montgomery
Mobile Phone
*
-
Area Code
Phone Number
Secondary Phone (if applicable)
-
Area Code
Phone Number
Primary Email
*
example@example.com
Additional Email (if applicable)
example@example.com
What is your primary address?
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How did you find out about Leadership Montgomery?
Social Media
Personal Contact(s)
Website
Other
Please specify
Personal Contact
Which Social Media Platform?
Facebook
Twitter
Instagram
LinkedIn
YouTube
Demographic Information:
Gender (disclosure not mandatory)
Male
Female
Non-binary/ third gender
Prefer to self-describe
Prefer not to answer
Race (optional) Leadership Montgomery seeks to reflect, cultural and ethnic diversity among its participants. Please indicate the racial/ ethnic category(ies) with which you identify.
African American
Asian
Caucasian
Hispanic
Middle Eastern
Two or More Races
Native American
Ethnicity
Hispanic or Latino
Non Hispanic or Latino
Pre-Course Info
Our goal is to ensure that all participants meet their organizational plan goals, no matter where they are on their race equity journey. Please complete the following questions so that we can gain a better understanding of where you and your organization are as it pertains to your goals.
1. What brings you to the REAL Inclusion Program? What makes this the right time for you to participate?
*
2. What outcome(s) do you hope to achieve within your organization as a result of participating in this program?
*
3. What outcome(s) do you hope to achieve personally as a result of participating in this program?
*
4. What issues related to racial equity/inequity are you seeing in your organization?
*
5. What is your organization currently doing with regards to racial equity?
*
6. How does racial equity impact you on a personal level?
*
7. What are your individual practices around inner work and personal development related to racial equity?
*
8. What questions do you have about this program or the expectations?
*
9. This program involves making a plan for your organization to operationalize race equity. Will you be the person responsible for implementing this plan in your organization?
Yes
No
Not Sure
Signature
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Leadership Montgomery requires certification by submitting an electronic signature. To certify your application, confirm your signature.
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