Coach Application </title</a> <form action="http://formmail.dreamhost.com/cgi-bin/formmail.cgi" method="POST"> <input type=hidden name="recipient" value="amy@grassrootsleadershipcollege.org"> <input type=hidden name="subject" value="Coach Application"> <input type=hidden name="print_blank_fields" value="1"> <input type=hidden name="date_offset" value="-5"> <input type=hidden name="redirect" value="http://grassrootsleadershipcollege.org/v2/thanks.html"> <b>Coach Application: Fall 2009</b><br> Applications due by August 3rd, 2009<br> <b><u>Personial Information</u></b><br> Name: <input type="text" name="Name" size="25" maxlength="100"><br> Home Address: <input type="text" name="Home Address" size="25" maxlength="100"><br> City: <input type="text" name="City" size="25" maxlength="100"><br> Zip Code: <input type="text" name="Zip Code" size="25" maxlength="100"><br> Home Phone Number: <input type="text" name="Home Phone Number" size="25" maxlength="100"><br> Work Phone Number: <input type="text" name="Work Phone Number" size="25" maxlength="100"><br> Cell Phone Number: <input type="text" name="Cell Phone Number" size="25" maxlength="100"><br> Email Address: <input type="text" name="Email Address" size="25" maxlength="100"><br> The GLC has permission to share contact information with classmates (Check one. GLC does not sell or share our database.) <input type="radio" name="Permission to share contact information"value="Yes">Yes <input type="radio" name="Permission to share contact information"value="No">No<br> Date of Birth (optional) mm/dd/yy: <input type="text" name="Date of Birth" size="25" maxlength="100"><br><br> Race/Ethnicity (this information is requested by some funding agencies):<br> <input type="radio" name="Ethnicity"value="African American">African American<br> <input type="radio" name="Ethnicity"value="Asian American">Asian American<br> <input type="radio" name="Ethnicity"value="Arab American">Arab American<br> <input type="radio" name="Ethnicity"value="Latino">Latino<br> <input type="radio" name="Ethnicity"value="Native American">Native American<br> <input type="radio" name="Ethnicity"value="White">White<br> <input type="radio" name="Ethnicity"value="Multi Ethnic">Multi Ethnic<br> <input type="radio" name="Ethnicity"value="Other">Other<br><br> <br><br>Gender: <input type="radio" name="Gender"value="Female">Female <input type="radio" name="Gender"value="Male">Male <input type="radio" name="Gender"value="Transgender">Transgender<br><br> Neighborhood Association or organizational affiliation (if applicable): <input type="text" name="Neighborhood Association or organizational affiliation" size="25" maxlength="100"><br><br> <b><u>SHORT ANSWER QUESTIONS:</u></b><br> Please tell us a little more about yourself by answering the following questions. Your answers do not need to be long no more than a few sentences.<br><br> Why would you like to be a coach for a developing grassroots leader?<br> <textarea name="Why would you like to be a coach for a developing grassroots leader?" rows=7 cols=70></textarea><br><br> Have you ever been mentored or coached by someone, formally or informally<br> <textarea name="Have you ever been mentored or coached by someone, formally or informally?" rows=7 cols=70></textarea><br><br> If so, what did you like about the experience?<br> <textarea name="If so, what did you like about the experience?" rows=7 cols=70></textarea><br><br> If so, what did you dislike about the experience?<br> <textarea name="If so, what did you dislike about the experience?" rows=7 cols=70></textarea><br><br> What do you think are some important skills needed to effectively coach a developing leader? Which of these skills do you bring to our program? What skills would you like to improve upon while a coach for the Grassroots Leadership College?<br> <textarea name="What do you think are some important skills needed to effectively coach a developing leader? And what skills do you bring and want to learn?" rows=7 cols=70></textarea><br><br> Describe interests or experiences (work, volunteer, or personal) that have prepared you for this role.<br> <textarea name="Describe interests or experiences (work, volunteer, or personal) that have prepared you for this role." rows=7 cols=70></textarea><br><br> If so, what did you dislike about the experience?<br> <textarea name="If so, what did you dislike about the experience?" rows=7 cols=70></textarea><br><br> Could you commit 3-5 hours/week to the GLC? Coaches are expected to attend most class sessions as well as to meet with their developing leader at least once a month. <input type="radio" name="Commit to 3 to 5 hours"value="Yes">Yes <input type="radio" name="Commit to 3 to 5 hours"value="No">No<br><br> <b><u>ADDITIONAL NEEDS:</u></b><br> The GLC will provide childcare, transportation, and meals for our participants, as well as other accommodations that make participation possible. Please let us know of any special needs you may have.<br><br> Childcare needs (children's names and ages): <br><textarea name="Childrens needs, names and ages" rows=7 cols=70></textarea><br> Transportation needs:<br><textarea name="Transportation needs" rows=7 cols=70></textarea><br> Dietary needs (vegetarian or other):<br><textarea name="Dietary needs" rows=7 cols=70></textarea><br> Other needs:<br><textarea name="Other needs" rows=7 cols=70></textarea><br> <input type="submit" value="Submit Application"> </form> To electronically submit your completed application click the "submit" button<br> or print out your completed application and mail it to: Grassroots Leadership College, <br>1321 E. Mifflin St. Suite 201, Madison WI 53703.