Leadership Louisville Program Application

Name

Please enter your name*

Prefix First Middle Last

Work

Job Title*

Organization*

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

Assistant Name (if applicable)

Providing the name and email of an assistant will ensure your assistant is copied on program-related emails.

Assistant Phone (if applicable)

Assistant Email (if applicable)

Personal

Home Address*

Street Address City State ZIP Code

Mobile Phone*

Personal Email*

Enter Email Confirm Email

What do you like to be called? (first name)*

If selected for this program, we'll order a permanent nametag for you. The nametag will include the first name you go by (entered above) 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 represented, 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*

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 must be 1,500 characters or less. (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.)*

What life experiences and perspectives do you bring to the class that would make you a unique participant?*

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 of your application to the Leadership Louisville program, as 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?*

Tuition Support

If not requesting tuition support, skip to the next section, "Program Commitments."

Tuition support MUST BE REQUESTED at time of application, and your application must be submitted by April 15, 2023. NO Requests will be considered after the tuition support application deadline.

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 after the class selection process is complete. You can request one of the amounts listed but understand that to serve as many needs as possible, the Leadership Louisville Center cannot provide the full amount of the tuition.

Our awards do not exceed 50 percent of the program cost. To receive consideration, the following questions must be answered completely and accurately.

Amount of tuitions support you are requesting:

25% ($1,550)

50% ($3,100)

A reminder that if you are requesting tuition support, your application is due by April 15, 2023.

Tell us more about your tuition request

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

Program Commitments

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

Uncertain at this time

Yes

Important - Please Read!

After clicking the Submit button, it may take a few moments to process your application - please wait at least a minute before hitting the Submit button again. 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. Please check your spam folder if it doesn't arrive.

If you have any technical difficulties with this application, contact Emalee Morley at (502) 561-5223.

Hidden

Amount of tuition support requested (dollar amount, no $ sign)

Name

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

Leadership Louisville Program Application

You must complete the entire application in one session.

Name

Work

Personal

Demographics

Short Answer

References

Tuition

Tuition Support

Program Commitments

Important - Please Read!

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