| 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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| Home Phone |
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| Other Phone |
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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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| Other 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 2010.
(Please contact
the office with any address changes and add
henaz@americanconferenceondiversity.org to
your safe senders list!) |
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| T-Shirt Size |
Small
Medium
Large
X-Large
XX-Large
Other:
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| Please provide the
following demographic information. Be as specific as possible.
This information is 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: |
| Sex or Gender |
Male
Female
Transgender/Transsexual
Other
Preferred Pronoun
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| Racial / Ethnic Background
(check all that apply and please type in specific ethnic origin) |
American Indian/Native American
Asian/Pacific Islander
Black/African/Caribbean
Latino(a)/Hispanic/Chicano(a)
Middle Eastern
White/European American
Other
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| Sexual Orientation/Identity (check
all that apply) |
Bisexual
Gay
Lesbian
Queer
Questioning
Straight / Heterosexual
Other
No Response
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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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| Position Applying For |
Counselor
Advisor
Co-Director
Medical Professional
Mental Health Professional |
Available Sessions
(please rank the sessions you can attend in order of preference; please note that YOUR FIRST CHOICE IS NOT GUARANTEED-you will be placed, if accepted, in the session that would most benefit from your specific identity and experience. Therefore, your availability will play a role in the selection process):
Session 1: July 24-30 (Staff arrives on the 24th)
Session 2: July 31-August 6 (Staff arrives on the 31st)
Yes, I will attend the mandatory staff training weekend on June 12-13, 2010.
Yes, I will attend the staff pre-training on the first day of my assigned 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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THE FOLLOWING 7 QUESTIONS ARE FOR NEW STAFF APPLICANTS ONLY
NEW STAFF APPLICANTS: Thank you for your application. If your application is accepted, you will be invited for an interview in February 2010. Information will be sent via email. Please add henaz@americanconferenceondiversity.org to your safe senders list to ensure you receive information in a timely manner. Your application may also be deferred until 2011 due to very limited spaces and demographic needs. Your commitment and dedication to social justice and Lead for Diversity are what make our community possible--thank you for spreading your passion and sharing your voice whether or not you become a part of the Lead for Diversity staff** Please scroll to the last page to sign and complete the application.
Attach a résumé where possible and appropriate.
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NEW STAFF APPLICANTS SUPPLEMENTAL QUESTIONS:
(1) Please give the name, relationship to you, email, and phone number of three references that you have known for at least three years who are not related to you and are familiar with your interests, extracurricular activities,
and have seen you in activist/leadership roles (traditional and nontraditional).
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| (2) Previous Lead for Diversity (formerly Anytown)
Experience (role and year):
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(3) How did you hear about Lead for Diversity? (reference)
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(4) Why do you
wish to be a part of the Lead for Diversity experience?
a. What do you expect
to gain as a result of being a staff member??
b. What do you expect to give as an LFD staff member?
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(5) What life or social justice experiences have prepared you to relate to and
guide delegates through their Lead for Diversity experience?
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(6) What do you believe would be your greatest challenge(s) as a staff member?
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(7) Please take the time now to think outside the usual "application box" and
express a piece of yourself that you would like to share with this community.
The way or method through which you express yourself is entirely up to you
and open to your interpretation—feel free to attach more paper or send
something else along with the application (via email/fax/mail). We are not
looking for a “right answer”; however, we are looking for a piece of you—so
take the time to “Be Real and Take Off Your Mask”! What we hear from Lead
for Diversity staff year over after year is that LFD can be an experience where
a piece of you is constantly being given, a real conversation is being had, a
safe community of sharing is being built. Through this question, our hope is to
get a peek at a portion of what you stand for and what you share with our
community. We thank you, in advance, for your honesty.
New Staff: Please continue to the end of the page to sign and submit the
application.
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THE FOLLOWING QUESTIONS ARE FOR RETURNING STAFF APPLICANTS ONLY
Thank you for your interest in returning as a staff member at Lead for
Diversity! Attached is an application form that must be filled out and returned
to the American Conference on Diversity by January 15, 2010. No applications
whatsoever will be considered after the deadline.
Please use this application as an opportunity for earnest self-reflection on the
reasons you became and remain involved in Lead for Diversity. If you are not
chosen to be on staff this summer, please continue to show your commitment
to the program, as you always have, through your actions in your work and
schools and by not giving up on the application process for next year. We hope
not to lose any of you in our fight for social justice.
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QUESTIONS 1-2 ARE FOR ALL RETURNING STAFF APPLICANTS:
(1) Please take one or two paragraphs to self-reflect and give honest feedback
on your previous performance(s) as a staff member, including what you think
you did well, as well as areas of improvement—if you were on staff in 2009,
please limit your feedback to 2009. How do you plan on addressing these
challenges this year?
(2) What professional training(s) or life experience(s) have you gained since your last Lead for Diversity session that will add to your ability to fulfill your position this year? How?
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| **QUESTIONS 3-6 ARE ONLY FOR THOSE RETURNING STAFF
WHO DID NOT APPLY IN 2009! IF YOU SUBMITTED AN
APPLICATION IN 2009, PLEASE CONTINUE TILL THE END OF
THE APPLICATION TO SIGN AND SUBMIT.
(3) What do you believe are your strengths and contributions to Lead for
Diversity’s staff team?
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| (4) What issues that we address at Lead for Diversity (race, sexual orientation, gender, body image, ability status, privilege, etc) are you least aware of or find most challenging? How do you plan on heightening your awareness of these topics to better prepare for your role at Lead for Diversity?
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(5) How do you show your commitment to the mission and values of Lead for Diversity throughout the year? What part of the mission is the hardest for you to adhere to when you are away from LFD?
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(6) What constructive feedback have you received in the past regarding some are of your performance at Lead for Diversity? How did you implement this feedback?
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ALL STAFF APPLICANTS MUST SIGN AND AGREE TO THE FOLLOWING:
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 employers, references, academic institutions and other organizations. 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:
- Complete all staff paperwork (including background check) in a timely manner
- Attend entire two-day training workshop for staff on June 12-13.
- Attend staff training 24 hours prior to your Lead for Diversity session
I hereby acknowledge that I have read and understand the preceding statement:
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 February 2010.
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Online Application