Developing Leader Application: Fall 2008

Tuition $100/semester or 5 Timebank hours — scholarships are available
Applications due August 1, 2008

PERSONAL INFORMATION:

Name:
Home address:
City:
Zip:
Work phone:
Home phone:
Cell phone:
E-mail address:

The GLC has permission to share contact information with classmates
(Check one. GLC does not sell or share our database.) Yes No

Date of Birth (optional) mm/dd/yy:

Race/Ethnicity (this information is requested by some funding agencies):
African American
Asian American
Arab American
Latino
Native American
White
Multi Ethnic
Other

Gender: Female Male Transgender

Neighborhood Association or organizational affiliation (if applicable):

SHORT ANSWER QUESTIONS:

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.

Please review the criteria and time commitment (3-5 hours/week) for participation in the Grassroots Leadership College and tell us why you are interested in participating and what you’d like to learn.

About Your Neighborhood

What neighborhood do you live in?

What do you like about it?

What do you dislike about it?

What are some ideas you have for a neighborhood or community project that you would like to work on through the GLC?
Are you currently pursuing any of these projects either individually or through your neighborhood association or community organization? Please describe.

Have you been involved with any neighborhood, school, or community groups, and, if so, which ones? If not, what kinds of groups are you interested in being involved with?

About Mentorship or Coaching

Have you ever been mentored or coached by someone, formally or informally?
Yes No

If so, what did you like about the experience?

What did you dislike about the experience?

List any individuals you have met or would be interested in having as a mentor/coach:

Could you commit 3-5 hours/week to the GLC (including time spent on your neighborhood/community project)?
Yes No

ADDITIONAL NEEDS:

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.

Childcare needs (children's names and ages):

Transportation needs:

Dietary needs (vegetarian or other):

Other needs: