ACHE-WI LDP 2025 Application

Contact Information
Name*

First NameMiddle InitialLast Name
Credentials
Company Name*
Title*
Preferred Email*
example@example.com
Gmail Email Address (documents are shared with the cohort via Google drive)*
LinkedIn Profile URL*
Home Mailing Address (for WHA Advocacy Day legislative visits planning):*
Street Address
Home Mailing Address continued*
City, State, Zip
Preferred Phone Number*

Area CodePhone Number
I am a member of the following (select all that apply):

ACHE-WINAHSE (National Association of Health Services Executives)NALHE (National Association of Latino Healthcare Executives)

Demographics
In principle and in practice, ACHE-WI values and seeks diverse and inclusive participation within the field of healthcare management. ACHE-WI promotes involvement and expanded access to leadership opportunity regardless of race, ethnicity, gender, gender identity, religion, age, sexual orientation, nationality, disability, appearance, geographic location, or professional level.
Date of Birth*

MonthDayYear
Date
Gender Identity*
Race/Ethnicity*

Experience
Total years full-time healthcare experience:*
Total years full-time healthcare leadership/management experience:*
Total number of years with current organization:*
Total number of years as a member of ACHE (post-administrative fellowship):*
How long have you been a member of ACHE overall (years):*
How long have you been a member of the ACHE Wisconsin Chapter (years):*
Please describe a significant accomplishment that you are most proud of:*
Please describe your short-term and long-term career plans:*
Briefly explain how you see this program advancing your career in healthcare management:*
Please describe what you bring to this cohort that is unique:*
Please share a brief bio:*

Support
The LDP program is a year-long commitment which requires time away from regular work duties. In order to get the most out of the program we ask that you have support from your organization, including your direct supervisor/administrator.
Administrator Name*

First NameLast Name
Administrator Title*
Administrator Email*
example@example.com
Please confirm that the administrator is agreeing to support the recommended employee throughout the course of the Leadership Development Program. Additionally, the recommending administrator supports the applicant in the commitment to the program and will ensure that the applicant dedicates the time necessary to complete the program.
I have approval from my administrator to participate in the ACHE-WI Leadership Development Program*

YesNo

Site Visits
Each Leadership Development Program participant will be asked to take leadership in the planning and coordination of a site visit typically including an overview of the organization, meetings or short presentations with key organizational leaders, facilities tour, and discussion of pertinent leadership and healthcare topics. Site visit itineraries will be tailored to the organization selected, availability of opportunities, and interests of participants; sample itineraries and site visit details will be discussed more during the Planning Session and with LDP leaders. The selection of organizations to host site visits will be determined with feedback from Leadership Development Program participants, LDP leaders and ACHE-Wisconsin Chapter leaders to provide a comprehensive experience.

To facilitate site visit planning, please list the healthcare or field-related organization(s) in Wisconsin for which you would be comfortable volunteering to request, plan and coordinate a site visit for Leadership Development Program participants. It is not required that you work for or have worked for organization(s) listed, however it is recommended that you have a relationship with one or more leaders of each organization.
Please choose THREE (3) preferred dates below.*

Thursday, June 19, 2025Thursday, July 17, 2025Thursday, August 21, 2025Thursday, October 23, 2025Thursday, January 15, 2026Thursday, February 19, 2026

Uploads
Upload Resume Here*

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Upload Organizational Chart Here*

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Upload Current Job Description Here*

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Submit Headshot Here*

Browse Files
If selected, we will use your photo on the cohort roster and ACHE Wisconsin Website. Cancelof

Participant Commitment
By signing below, you acknowledge that you have read and agree to the Participant Commitment.
Applicant Signature*

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Print Name*

First NameLast Name
Date*

MonthDayYear
Date
Wisconsin Chapter of the American College of Healthcare Executives

Leadership Development Program 2025-2026

ACHE-WI@badgerbay.co

For more information, please visit http://wisconsin.ache.org/professional-development/leadershipdevelopment-program/

Thank you for your interest in the ACHE-Wisconsin Chapter Leadership Development Program.

Sincerely,

Leadership Development Program Committee
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Leadership Development Program - 2025 Application