REAL Inclusion Registration Form

Personal Information:
Salutation*
First Name*
Middle Initial
Last Name*
Suffix
Nickname/Preferred Name*
Phonetic Pronunciation of Name*
Preferred Pronouns*
Company/Agency
Job Title
What other LM programs (if any) have you participated in?

Emerging LeadersCORESenior Leadership Montgomery
Mobile Phone*

Area CodePhone Number
Secondary Phone (if applicable)

Area CodePhone Number
Primary Email*
example@example.com
Additional Email (if applicable)
example@example.com
What is your primary address?*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you find out about Leadership Montgomery?
Please specify
Personal Contact
Which Social Media Platform?
Demographic Information:
Gender (disclosure not mandatory)

MaleFemaleNon-binary/ third genderPrefer to self-describePrefer 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 AmericanAsianCaucasianHispanicMiddle EasternTwo or More RacesNative American
Ethnicity

Hispanic or LatinoNon 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?

YesNoNot Sure
Signature

Clear
Leadership Montgomery requires certification by submitting an electronic signature. To certify your application, confirm your signature.*

Confirm Signature
Please verify that you are human*
Should be Empty:

Personal Information:

Demographic Information:

Pre-Course Info