| Full Name |
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| Name I Prefer to
Be Called |
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| Date of Birth |
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| Occupation/Title |
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| Email |
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| Cell Phone |
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| Alternate Phone |
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| Alternate Phone 2 |
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| This is my |
College Phone
Work Phone |
| Home Address |
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| City |
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| State |
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| Zip |
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| College/Work Address
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| City |
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| State |
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| Zip |
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| This is my |
Home Address
Work Address |
Please specify the address at which you would like to receive mail between February and June.
(Please contact
the office with any address changes and add
pam@americanconferenceondiversity.org to
your safe senders list!) |
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| T-Shirt Size |
If Other:
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| Please provide the following demographic information. Be as specific as
possible. This information will be used to ensure that we have as diverse a
staff as possible. Only American Conference on Diversity staff and Lead
for Diversity Advisory Council members see your responses: |
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| Religious Identity /
Belief System |
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| Languages Spoken |
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Is there any other information about
your identity that you would like to share (e.g. physical ability,
socioeconomic class, immigrant status, etc.)?
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The number of applicants may exceed the number of slots we have open for staff members. Please check this box if you would like to apply as an alternate,
understanding that you will serve as a standby and will be expected to serve on staff in the event that a staff position for Lead for Diversity 2011
becomes available. |
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There are many ways to support Lead for Diversity throughout the year. Please read the following and place a check mark by each activity in which you
are interested in participating.
(1) What strengths and contributions will you bring to the Lead for Diversity 2011 staff?
(2) Please describe the professional training(s) and/or life experience(s) you have gained since your
last Lead for Diversity session and how it (they) will help you contribute to LFD this year.
(3) Why do you want to be on staff this year?
(4) Describe your favorite or most memorable moment as a staff member with LFD / Anytown. What
makes it your favorite or most memorable?
(5) How has serving as a Lead for Diversity staff member impacted your life?
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| Position Applying For |
Co-Director
Advisor
Counselor
Medical Professional
Mental Health Professional |
Agreement to Attend Staff Trainings
Yes, if selected as a staff member or alternate, I will attend the entire staff training on June 11, 2011.
Yes, if selected as a staff member, or if serving as an alternate who is replacing a staff member, I will
attend the entire Pre-Camp Training on July 23, 2011.
Agreement to Attend the Lead for Diversity 2011 Session
Yes, I will attend the entire Lead for Diversity 2011 Session, if serving on staff.
In the Event Unable to Serve on Staff
As soon as possible, I will notify the American Conference on Diversity about my inability to serve, in the
event that I am selected as a staff member but am no longer able to serve on staff.
If Selected to Be an Alternate
I understand that I am expected to attend the staff training in June. I further understand that I may be
selected to be on staff if a vacancy becomes available; should that occur, I will be expected to attend
the entire Pre-Camp training and Lead for Diversity session.
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Please list below any convictions
for misdemeanor felony offenses. Note that your participation
as a Lead for Diversity staff member will be reviewed based upon the information
provided. A formal criminal background check will be conducted upon acceptance and placement at a session.
No convictions
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I certify that the information provided in this application is true and
complete. I authorize American Conference on Diversity to investigate
all statements in this application and to secure any necessary
information from all applicable parties. I also agree to execute any additional written
authorization necessary for the American Conference on Diversity to
obtain access to and copies of records pertaining to this information. I
agree to release any person, company, or other institution from any and
all cause of action that otherwise might arise from supplying the
American Conference on Diversity with information it may request
pursuant to this release.
I understand that any Volunteer Services with American Conference on
Diversity is contingent upon receipt of satisfactory responses to any or
all investigations conducted by American Conference on Diversity. I
understand that any false answers, statements, or misrepresentations by
omission made by me on this application or any related document will be
sufficient for rejection of my application, or for my immediate
discharge if discovered after I begin providing services.
I agree to comply with all policies, procedures, and rules applicable to
employees of American Conference on Diversity and I understand that any
violation may result in my dismissal.
I further agree to do the following:
1. Complete all staff paperwork (including background check) in a
timely manner
2. Attend the entire staff training on June 11, 2011
3. Attend, and be on time for, pre-camp training (i.e. staff training the day before the delegates
arrive at my Lead for Diversity session) on July 23, 2011.
Signature:
Date:
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Thank you for your interest in Lead for Diversity and for filling out
this application!
If your application is accepted, you will be contacted by early March, 2011.
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Online Application