Bingham Fellows Application

Name

Please enter your name*

Prefix First Middle Last Suffix

Work

Job Title*

Company*

Industry*

Please indicate the industry/segment you work in.

Year Current Employment Began*

Work Address*

Street Address City State ZIP Code

Work Phone*

Work Email*

Enter Email Confirm Email

Personal

Home Address*

Street Address City State ZIP Code

Mobile Phone*

Personal Email*

Enter Email Confirm Email

Preferred FIRST NAME ONLY (for class nametag)*

If selected for this program, we'll order a permanent nametag for you. The nametag will include your preferred first name as well as your last name.

Dietary Restrictions*

If none, type "none."

Special Accommodations*

Nursing mothers, wheelchair accessibility, etc. If none, type "none."

Full Name for Press Release*

If selected for this program, we'll list your name in a press release. Please indicate how you would to see your name appear, including any post-nominal letters. (Please note that the Leadership Louisville Center adheres to AP style and may edit your entry.)

Demographics

Diversity is an important part of our mission. In an effort to understand our applicants and ensure all populations are served, we have a few questions we'd like to ask. Please know that:

- This information is used to collect demographic data on our applicants.
- The information will not be used for a discriminatory purpose.
- Only Leadership Louisville Center staff and the selection committee will have access to this information.
- Your responses will be kept private and secure.

Date of Birth*

MM/DD/YYYY

Gender*

Preferred Pronouns (optional)

If you provide pronouns, they will appear on your permanent nametag. For example: "She/her/hers", "He/him/his", "They/them", "Ze/zir/zirs"

Race/Ethnicity*

Hold down the CTRL key to select more than one value.

Other Race/Ethnicity

Are you a veteran of the U.S. armed forces?*

Do you identify as part of the LGBTQ+ community?

Are you Foreign Born?*

If foreign born, what is your country of origin?

How did you hear about this program? (check all that apply)*

Hold down the CTRL key to select more than one value.

If you were referred, who referred you?

Short Answer

Answers of 1500 characters or less per question are allowed. (approximately 200 words)

Please list any advanced degrees, awards, and/or recognitions you have received. Also please list other leadership programs (including the year) in which you have participated, whether Leadership Louisville Center programs or other leadership programs.*

Please describe your community involvement, sharing the names of organizations and roles served (volunteerism, board or committee service, etc.)*

After reading the report "A Safer City By Design," what do you feel is the most critical issue that needs to be addressed and how might a Bingham Fellows class provide solutions?*

What unique skills, perspectives, and/or passions would you bring to the Bingham Fellows topic of 2024?*

Please discuss your capacity and the time commitment you are willing to dedicate to this program.*

References

Please provide the names of two individuals who will serve as references. Please ensure they're aware regarding your Bingham Fellows Class of 2023 Application. We will be in touch if questions arise.

Reference Name (#1)*

Reference's Title (#1)*

Reference's Company (#1)*

Reference's Preferred Phone (#1)*

Reference Name (#2)*

Reference's Title (#2)*

Reference's Company (#2)*

Reference's Preferred Phone (#2)*

Tuition

How do you plan to cover the cost of tuition?*

Sponsored by a company or organization
I will be paying my own tuition
Uncertain at this time

Tuition Support

Tuition support MUST BE REQUESTED at time of application. NO Requests will be considered after the application deadline. If not requesting tuition support, answer the first question and skip to the next section.

Are you requesting tuition support?*

The Leadership Louisville Center believes in the collective power of diverse voices, perspectives, and backgrounds. We have tuition support funds designated specifically for diversity in all its forms and for those to whom our program costs would be a barrier to participation. Requests for support are not shared with the selection committee and will only be considered only after the class selection process is complete. You can request any amount, but understand that to serve as many needs as possible, the Leadership Louisville Center cannot provide the full amount of the tuition.

Our awards typically do not exceed 50 percent of the program cost (which would be $2400), but you may request more if needed to enable your participation. To receive consideration, the following questions must be answered completely and accurately.

Amount of tuition support requested

25% ($1,200)
50% ($2,400)

Tell us more about your tuition request

Will you be able to participate in this program if your tuition support is not granted?

Program Committments

Do you have the full support of your employer for the time commitment required to participate in Bingham Fellows?*

Yes
No
Uncertain at this time

Please check box to confirm:*

I have read the text below and understand there are mandatory days.

I have checked the program calendar (linked Immediately below) and read the attendance policy (linked immediately below.) I understand that the Bingham Fellows opening session in January and the two-day retreat in May are mandatory in their entirety, and missing any portion of these events will disqualify me from the program.

Program Calendar

Attendance Policy

Please check box to confirm:*

I affirm this information is accurate.

I affirm that this information is accurate at the time of this submission. If it changes, it is my responsibility to notify Sara Bowman (502) 753-1492, or it may invalidate my application.

Please check box to confirm:*

I understand the Bingham Fellows time commitment

I understand that a major component of the program is the Bingham Fellows project. This project will require significant time outside of program days. I will be an active participant on my project team.

Please check box to confirm:*

I understand this program requires support from my employer and family.

I understand that to commit to the Bingham Fellows program and the Bingham Fellows project will require support from my employer, family, and other obligations. The program is only successful when all participants are committed to its completion.

Important - Please Read!

After clicking the Submit button, it may take a few moments to process your application. Once your application is submitted successfully, you will see a confirmation message and receive an email within five minutes that contains all the information you submitted. If you have any problem with this application, contact Emalee Morley at emorley@leadershiplouisville.org.

Email

This field is for validation purposes and should be left unchanged.

Bingham Fellows Application

Name

Work

Personal

Demographics

Short Answer

References

Tuition

Tuition Support

Program Committments

Important - Please Read!

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