2024 LFC Additional Team Member Form

NLAPH 2024 Lead Free Communities Additional Team Member Form
Welcome to the National Leadership Academy for the Public's Health (NLAPH). As part of the onboarding process for the NLAPH program, you will need to complete this NLAPH 2024 Lead Free Communities - Additional Team Member Form.

Before beginning this application, please be sure to:

1. Gather all required documents in PDF format:
- Resume or CV
- Individual Letter of Support: This should come from your respective organization, written by the Executive Director or head of your organization. The letter should communicate awareness and endorsement of participation in the NLAPH Program (in tandem with the community grant) and acknowledge the additional time and effort required to participate in workshops and coach-team meetings.
2. Complete and submit this online form with all required information and support documents.
Required fields are marked with an asterisk (*).
Form title & related program
1. Team Name*
2. Team Location*
3. LAPH Cohort Program*

I. Team Information

This section is to be filled out in it's entirety by a team member who is applying in addition to the team members included on the original application.
A1. Additional Team Member *

First NameLast Name
A2a. Preferred Gender Pronouns *
A2b. Other preferred pronouns, if not mentioned above:
A3. Position / Title *
A4. Degree(s) *
A5. Organization *
A6. Street Address *

Street Address

Street Address Line 2

CityState or Territory (two-letter code)

Zip Code
A7. City *
A8. State / Territory *
A9. Zip Code *
A10. Email *
example@example.com
A11. Cell Phone *
A12. Work Phone *
Sectors, Disciplines, and Leadership Experience

The questions below ask you to select the sector(s) and discipline(s) most applicable to your work. See the Team Characteristics, Composition & Roles page for examples of sectors and disciplines. If you need further clarification, please contact us.
A13a. Select the sector in which you work. *
A13b. If other, please describe.
A14a. Indicate the discipline that you use to describe your work. *
A14b. If other, please describe.
A15a. Indicate your leadership level (including current and previous work). *
A15b. How many years in leadership do you have? *
A15c. Describe your leadership experience: *

Approx. 200 words0/200
Your Experience Working as a Team
A16. How familiar are you with the best practices related to the issue being addressed in your Applied Health Leadership Project (AHLP)? *

Very familiarSomewhat familiarNot familiar
A17. How long have you served on this team applying for NLAPH? *
A18. What is your role on the team? *

Approx. 50 words0/50
A19a. Have you previously participated in a leadership development program?*

YesNo
A19b. If yes, please list programs and corresponding dates:

Approx. 150 words0/150
A20. What leadership skills do you hope to gain by participating in NLAPH? *

Approx. 200 words0/200

II. Supporting Documentation

Please upload the required documents below in PDF format.
H1. Curriculum Vitae (in PDF format) *

Browse Files
Please submit all pages as one PDF. Cancelof
H2. Letter of support from your organization (in PDF format) *

Browse Files
Please submit all pages as one PDF. Cancelof

Final Checklist
You have reached the submission section. Before submitting, please:

1. Print a completed copy to save for your records
2. Read the Submission Statement below
3. Press the 'Submit' button only if you agree with the Submission Statement

Submission Statement

By submitting this form, I declare that all my organization's responses are accurate and true, to the best of my knowledge.
Should be Empty:

NLAPH 2024 Lead Free Communities Additional Team Member Form

I. Team Information

II. Supporting Documentation

Final Checklist