| Full Name |
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| Name I Prefer to
Be Called |
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| Home Address |
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| City |
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| State |
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| Zip |
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| Home Phone |
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| Cell Phone |
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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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| College/Work Phone |
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| Email |
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| Social Security # |
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| Date of Birth |
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| I Prefer to be Reached
By |
Home Phone
School/Work Phone
Cell Phone |
| 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: |
| Gender |
Male
Female
Transgender
Other
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| Racial / Ethnic Background
(check all that apply and please specify ethnic origin) |
American Indian/Native American
Asian American
Black / African American
Latino(a)/Hispanic/Chicano(a)
Middle Eastern
Other
White/European American
|
| 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
check all that you are able to attend; note that staff arrive
on the day before): |
Session 1: July 6-11
Session 2: July 20-25
Session 3: August 3-8
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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.
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Experienced Staff ONLY: Have you
completed any advanced training, received a degree, etc. since
your last time on staff?
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NEW STAFF APPLICANTS MUST COMPLETE QUESTIONS 1-8 BELOW!
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 21-22
- 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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NEW STAFF APPLICANTS SUPPLEMENTAL QUESTIONS:
(1) Please give the name, address, and phone number of three
(3) references that you have known for at least three years who
are not related to you. If you are currently a high school student,
please give the name, school, and phone number of three (3)
members of a school faculty or administration familiar with
your schoolwork and conduct.
(2) Please fill in your educational background below. Complete
for the highest level attained. If you did not receive a degree/diploma,
indicate number of years completed Include the school, location,
degree/diploma/course of study, and date earned, as well as
organizations, clubs, memberships, and honors:
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| (3) Previous Lead for Diversity (formerly Anytown)
Experience (role and year):
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(4) Referred to Lead for Diversity
by (include your relationship to that person):
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(5) Why do you
wish to be a part of the Lead for Diversity experience? What do you expect
to gain as a result of being a staff member?
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(6) What specific
qualifications, strengths, or insights would you bring to the
position for which you are applying? For those applicants who have not been to Lead for Diversity, What training or experience will be of assistance in assuming your position on staff?
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(7) After your session,
in what ways would you actively support the delegates becoming
change agents in their schools, communities, houses of worship,
and families?
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(8) FOR LEAD FOR DIVERSITY (FORMERLY ANYTOWN)
GRADUATES ONLY: Often, it is challenging for counselors to
be comfortable with being role models to their peers. Accepting
this challenge can begin by accepting the idea that the purpose
of going to Lead for Diversity is not to attempt to repeat the delegate
experience but to facilitate the best possible experience for
others. Please comment.
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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 invited for an interview to take
place in March 2008.
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Online Application