Encore Louisville Application

This application will be used to select participants for the Encore Louisville Class of 2023. Please review the Program Calendar before submitting your application.

In addition to completing this application, please send a headshot photo via email to Aimee Jewell.

You must complete the entire application in one session. Before beginning the application, we recommend you gather the information you need and compose the short answer responses in another word processor (you can copy and paste into the application).

If you encounter any problems submitting this form, please contact Emalee Morley at emorley@leadershiplousiville.org.

"*" indicates required fields

Name

Please enter your name*

Prefix First Middle Last Suffix

Current Work Information (skip this section if not applicable)

Job Title

Company

Work Address

Street Address City State ZIP Code

Work Phone

Work Email*

Please enter work email, or your preferred email address.

Enter Email Confirm Email

Personal

Home Address*

Street Address City State ZIP Code

Mobile Phone*

(###) (###-####)

Personal Email*

Enter Email Confirm Email

Which email would you prefer we use in communcations?*

Which phone number would you prefer we use in communcations?*

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*

Race/Ethnicity*

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

Do you identify as part of the LGBTQIA+ community?*

Are you foreign born?*

If foreign born, what is your country of origin?

If not from Louisville, enter hometown city and state:

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

If you were referred, who referred you?

Career Information

Employment status*

1. Employed (Not retired)

2. Retired and now self-employed

3. Retired or retiring this year - not working post-retirement

Job Title (pre-retirement)

If you entered “Retired” above, please indicate the title of your last role (or the role where you spent most of your career, whichever you prefer).

Company (pre-retirement)

If you entered “Retired” above, please indicate the company of your last role (or the role where you spent most of your career, whichever you prefer).

Industry (where you've spent most of your career)*

Please provide a one-paragraph biography describing your career, experiences, and skills. This will be shared with other Encore Louisville participants in a class handbook and will be provided to nonprofits that you would be working with.*

Your Company and Job Title (for publication)

PLEASE READ: Please indicate your preferred title and company for publication on our website, in press releases, and in the graduate directory. The company name you provide will also be used on your nametag when you attend Leadership Louisville Center events. In the case of those retired and now self-employed, you might enter "President" for your job title, and "Jones Consulting" for your company. If you are retired and not employed, please put "Retired" for your job title, and for company, specify how you'd like to be represented, for example, "Retired Healthcare Executive", or LG&E and KU Energy, Retired." See examples of how our current class is represented here: Encore Louisville Class of 2022 Roster

Current Job Title (for publication, if applicable, or enter "Retired")

Current Company (for publication, if applicable, or enter "Retired")

Commitment

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. The application deadline is Friday, November 11, 2022 at 11:59 p.m. If you have any problem with this application, contact Emalee Morley at emorley@leadershiplouisville.org.

Phone

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