REAL Inclusion Registration Form

REAL Inclusion Registration Form - Cohort 7

Personal Information:
Salutation*
First Name*
Middle Initial
Last Name*
Suffix
Nickname/Preferred Name*
Phonetic Pronunciation of Name*
Preferred Pronouns*

he/him/hisshe/her/hersthey/them/theirsze/zir/zirsPrefer not to answerOther
Company/Agency*
Job Title*
What other LM programs (if any) have you participated in?

Emerging LeadersCOREEncore (formerly Senior 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:

In REAL Inclusion, we seek to reflect the diversity of Montgomery County and the DMV region. We ask for demographic information from our participants to ensure we are being inclusive and creating a sense of belonging in our program. We acknowledge that demographic categories can feel limiting, are a social construction and do not encompass the wide range of people’s identities. The following questions are optional, and your responses will not be shared outside this organization.
What is your gender identity? (Select all that apply)*

ManWomanNonbinary or Gender non-conformingTransgenderPrefer to self-describePrefer not to answerOther
How do you identify racially and/or ethnically? (Select all that apply)*

American Indian, Native American, Indigenous or Alaska NativeAsian or South AsianBlack or African AmericanLatino/a/x/e or HispanicMiddle Eastern/North African/West Asian (MENA/WANA)Native Hawaiian or Other Pacific IslanderWhiteBiracial, mixed-race, or multiethnicPrefer not to answerOther
Are there any other identities that you bring into the space?
Generation: What generation do you identify as part of?*

Gen Z (born between 1997-2012)Millennial (born between 1981-1996)Gen X (born between 1965-1980)Boomer (born between 1946-1964)Silent (born between 1928-1945)Prefer not to answerOther
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? In your response please describe your organizational culture and commitment to racial equity.*
6. How does racial equity impact you on a personal level?*
7. Describe any self-work and/or learning you have done/are doing to understand racial equity*
8. What questions do you have about this program or the expectations?*
9. This program involves developing an action plan to operationalize racial equity in your organization. Will you be the person responsible for implementing this plan in your organization?*

YesNoNot Sure
10. Are you able to commit to attending all of REAL Inclusion Sessions? (Check all that apply). If you need to miss more than two sessions, please get in touch with us directly.

January 28, 2025February 25, 2025March 25, 2025April 22, 2025May 20, 2025June 24, 2025
11. Do you have any access or learning needs (i.e. hard of hearing, rest for your eyes from the screen, large print, physical movement, etc.) that you’d like us to know about in advance? If so, please share how we can best support you.*
Additional Information
Volunteer Activities & Community Involvement:
Please list, in order of importance to you, the nonprofit, civic, professional, social, religious, athletic or other organizations in which you are or have been involved with.
Dietary Restrictions*

Dairy FreeGluten FreeHalalKosherPescetarianVeganVegetarianOther
Please submit a high-quality .jpg or .gif file of your headshot *

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REAL Inclusion Registration Form - Cohort 7

Demographic Information:

Pre-Course Info

Additional Information