Ellevate Louisiana Membership Scholarship Application Form
Section 1 | Initial Eligibility
ELIGIBILITY NOTICE: A “No” response to Question 2 by a current or prior scholarship recipient, or to Questions 3 or 4 by any applicant, means the applicant is not eligible under the current scholarship requirements.
Is this your first application for an Ellevate Louisiana membership scholarship?
Yes
No- I am a current or prior scholarship recipient
If you are a current or prior scholarship recipient reapplying for assistance, did you satisfy all terms of your previous scholarship by paying all dues owed, actively participating in at least one Ellevate standing or policy committee, and attending at least one in-person Ellevate event during the scholarship year?
Yes
No
Not applicable- I am a first time applicant
Have you reviewed and do you understand the scholarship terms stated above?
Yes
No
If selected, are you willing and reasonably able to actively participate in at least one standing or policy committee and attend at least one in-person Ellevate event during the scholarship year?
Yes
No
Section 2 | Applicant Information
Name
First Name
Last Name
Preferred Name
Email Address
example@example.com
Mobile Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Based on your parish of residence, which Ellevate region do you live in? Select one.
Acadiana
Bayou
Capitol Region
Central Louisiana
Northeast Louisiana
Northwest Louisiana
Southeast Louisiana
Southwest Louisiana
If you primarily work in an Ellevate region other than the region where you live, please list the work region or regions
Current employment status
Employed full-time
Employed part-time
Self-employed or business owner
Contract or temporary employment
Student
Seeking employment
Retired
Other
Current occupation or title
Current employer or organization (if applicable). If not applicable, enter “N/A.”
Industry or professional sector
Early Education or K-12 Education
Higher Education
Workforce Development
Healthcare
Behavioral Health
Government or Public Administration
Law or Public Policy
Finance or Accounting
Taxation or Economic Development
Environment or Infrastructure
Energy
Construction or Engineering
Nonprofit or Philanthropy
Communications or Media
Agriculture
Technology
Other
How did you learn about Ellevate Louisiana? Select all that apply, then provide the requested details below.
Current Ellevate member or staff
Attended an Ellevate event
Employer or professional organization
Social media
Ellevate website
Community event
Other
Please identify the specific person, event, program, employer or organization, social media platform, website page, community event, or other source
Section 3 | Membership and Scholarship Request
Which membership level are you seeking?
Executive Membership- $500 annual dues
Under 35 Executive Membership- $300 annual dues
If you selected Under 35 Executive Membership, provide your date of birth. Eligibility is determined as of the membership start date. This information will be used only to confirm eligibility for the Under 35 membership rate. Date of birth:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Which circumstances materially affect your present ability to pay membership dues? Select all that apply.
Unemployment or recent job loss
Underemployed or reduced work hours
Reduced household income
Early-career compensation
Student or education-loan obligations
Employer or organization does not provide professional-development funding
Nonprofit/public sector compensation limitations
Self-employment or new-business income variability
Significant unexpected household expense
Immigration or work-authorization-related employment interruption
Other material circumstances
None of the above
Which statement best describes your present ability to pay the applicable membership dues?
I cannot reasonably pay the dues without scholarship assistance
I could pay a limited portion, but paying the full dues would create a material financial hardship
I could pay a substantial portion, but not the full dues
I could pay the full dues by reducing discretionary spending
I can pay the full dues without material hardship
Approximately what percentage of the applicable membership dues can you reasonably pay personally?
0% to 19%
20% to 39%
40% to 59%
60% to 79%
80% or more
What dollar amount can you personally contribute toward the annual membership dues
Have you inquired whether your employer or organization offers reimbursement or professional-development funding for membership dues?
Yes- sufficient funding is available to pay the full dues
Yes- partial funding may be available
Yes- I confirmed that membership dues are not eligible
No I have not inquired
Not applicable- I am not currently employed or am self-employed
Please explain your answer above.
If your employer or organization offers reimbursement or funding, have you requested/applied for it?
Yes, and reimbursement or funding was approved
Yes, and the request/application was denied
Yes, and the request is pending
No
Not applicable because my employer does not offer this benefit
Not applicable because I am not currently employed or am self-employed
Please explain your answer above.
Apart from employer or organizational funding reported above, has another person or organization already committed to pay any portion of your membership dues? Applicants are not expected to seek funding from another individual or organization before applying for a scholarship.
Yes
No
If you selected Yes, please indicate the amount that has been committed.
Briefly explain why you are seeking scholarship assistance, including any circumstances affecting your ability to pay the applicable membership dues and any information not fully reflected in your responses above.
Section 4 | Engagement, Leadership, and Participation
Why are you interested in joining Ellevate at this point in your career or community involvement? Describe what prompted you to apply now, what you hope to gain from membership, and how you expect to use the experience in your professional or community work.
Briefly describe one specific experience in which you worked with people who held different political, policy, professional, or community perspectives to achieve a shared objective. Identify the objective, the differing perspectives, the actions you personally took to support collaboration, and the result or lesson learned.
Identify up to three significant leadership, professional, civic, volunteer, educational, or community activities from the past five years. For each activity, provide the organization, your role, dates of involvement, approximate time commitment, and a brief description of your most meaningful responsibilities, contributions, or results. Applicants are not required to list three activities and will not be penalized for listing fewer.
Of the activities listed in Question 30, identify the one that best demonstrates your leadership or community impact. Describe one specific contribution, initiative, accomplishment, or result you helped achieve, your individual role in achieving it, and any measurable or observable outcome.
Which of the following experiences have given you insight into issues affecting Louisiana communities? Select all that apply. You are not required to disclose private personal or family information, and responses should be considered only to understand the perspectives and experience an applicant may contribute to Ellevate.
Parent or guardian of school-age children
Early childhood caregiver or educator
Student, graduate student, or adult learner
Public school, charter school, or higher education board/committee participation
Experience with cancer-related care, caregiving, support, education, or advocacy
Experience with healthcare access, patient support, caregiving, or family caregiving
Experience with disability access, chronic-illness support, or behavioral-health services, caregiving, or advocacy
Small business owner, entrepreneur, or self-employed professional
Workforce development, hiring, training, or human resources experience
Experience with employment disruption, career transition, or financial barriers affecting individuals or communities
Environmental, conservation, agriculture, flooding, coastal, or infrastructure-related involvement
Volunteer or leadership service in a nonprofit, faith-based, civic, neighborhood, or community organization
Experience living or working in a rural community
Experience living or working in an underserved or economically disadvantaged community
Advocacy, public policy, legislative, government, or regulatory experience
Other relevant personal, volunteer, educational, or community experience
Prefer not to answer
What knowledge, skills, experience, or perspective would you contribute to Ellevate Louisiana? Briefly explain how your contribution could strengthen Ellevate’s membership, programs, committees, or policy work.
Which Ellevate committee or committees would you be willing and prepared to join and actively participate in if selected for a scholarship? Select at least one. Please review our website for further information on our committees.
Cancer Advocacy
Early Childhood Education & K-12
Health & Wellness
Taxation & Economic Development
Workforce & Higher Education
Membership Committee
Events Committee
Fundraising & Development Committee
Which statement best describes your ability to accommodate virtual committee meetings held during weekday business hours?
Yes, I am generally available during weekday business hours
Yes, my employer or work schedule allows flexibility to participate in periodic daytime meetings
yes, with advance notice I can arrange my schedule to participate
Possibly, I would have difficulty participating in meetings held during weekday business hours
Ellevate committees generally meet virtually during weekday business hours. Based on that schedule, approximately what percentage of committee meetings could you realistically attend and actively participate in?
Nearly all meetings (75-100%)
Most meetings (50-74%)
Some meetings (25-49%)
Few meetings (less than 25%)
Uncertain
If you anticipate attending fewer than 75% of committee meetings, briefly describe any scheduling limitations and how you plan to meet the participation requirement.
Are you reasonably able to attend at least one in-person Ellevate event in Louisiana during the scholarship year?
Yes
Yes, but only if held in my Ellevate region or within approximately a one-hour drive of my residence
Yes, but I may require advance notice or an accommodation
No
Section 5 | Confidential Political Affiliation Information
Political-affiliation disclosure is required because Ellevate Louisiana is a cross-partisan organization that values diversity and seeks balanced representation across political parties. This confidential information is collected solely to monitor the aggregate composition of Ellevate’s membership. It will not receive points or affect the applicant’s financial-need determination.
How do you currently describe your political affiliation?
Democrat
Republican
Independent or no party affiliation
Another affiliation
If you chose "Another affiliation" please explain.
Section 6 | Reference
Provide one professional, civic, volunteer, educational, or community reference who can speak to your participation history, leadership experience, reliability, or ability to fulfill commitments. Obtain the reference’s permission before providing their contact information.
Reference Name
Reference organization and title
Reference email address
Reference telephone number
Is the reference currently an Ellevate member?
Yes
No
Unsure
How long has the reference known you, and in what capacity?
Section 7 | Certifications and Acknowledgements
Check the box to confirm your agreement.
Accuracy certification: I certify that the information supplied in this application is true and complete to the best of my knowledge.
Scholarship discretion: I understand that satisfying the minimum eligibility requirements does not guarantee a scholarship.
Award amount: I understand that a scholarship may cover up to 80% of the applicable membership dues and that Ellevate may award less than the percentage requested.
Applicant contribution: I understand that submitting this application does not obligate me to accept a scholarship or pay membership dues. If I am offered and accept a scholarship, I will be responsible for paying the portion of the applicable membership dues not covered by the scholarship.
Committee participation: If selected, I agree to actively participate in at least one Ellevate standing or policy committee during the scholarship year.
In-person attendance: If selected, I agree to attend at least one in-person Ellevate event during the scholarship year.
Participation tracking: I understand that Ellevate may track my committee participation and event attendance to administer the scholarship program and evaluate a future renewal application.
Annual term and reapplication: I understand that the scholarship is for one year, does not automatically renew, and requires a new application for future scholarship assistance.
Mission and conduct: I agree to participate respectfully in Ellevate’s data-driven, non-partisan work and to engage constructively with members who hold different perspectives.
Electronic signature — type or print your full legal name.
Date signed
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
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