Fall 2021 Virtual Leadership Academy Application FormFall 2021 Application General InformationName* First Last Email* Phone*Mailing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Current Position/Title*Type of Position*Check all that apply (Hold CTRL and select)AttorneyLegal AdvocateCommunity OrganizerCommunity AdvocateSocial Service ProviderExecutive LeadershipBoard MemberFundraising/Resource Development/CommunicationOperational/Human Resources/ManagerOtherIf you selected "Other," please describe:Current Employer(s)*If not currently employed please indicate any organizational/community affiliationsType of Employer*(Check all that apply)Civil Legal AidCriminal JusticeJuvenile JusticeCivil Rights/AdvocacyNonprofitPublic SectorPro Bono ProviderLaw SchoolOther EducationSocial ServiceCommunity-Based OrganizationHealth CareOtherIf you selected "Other," please describe:Primary Washington Counties Where You Work*Check all that applyAll Counties / StatewideAdamsAsotinBentonChelanClallamClarkColumbiaCowlitzDouglasFerryFranklinGarfieldGrantGrays HarborIslandJeffersonKingKitsapKittitasKlickitatLewisLincolnMasonOkanoganPacificPend OreillePierceSan JuanSkagitSkamaniaSnohomishSpokaneStevensThurstonWahkiakumWalla WallaWhatcomWhitmanYakimaRace/Ethnicity*Gender Identity*Years of Professional Experience*0-56-1011-1516-2021-2526-3031-3540 or moreEssay QuestionsWhat do you hope to gain, both personally and professionally, through participation in the Leadership Academy?*Which communities and constituencies do you primarily work with in your current position? What are a few of the key issues these communities face regularly that intersect with the justice systems and/or social, racial, economic, or other structural inequities?*How will the knowledge you gain through the Leadership Academy help you serve the communities and constituents you work with?*Which coalitions and networks are you engaged in that you might be willing to share and grow as a part of your involvement in the Leadership Academy? Which coalitions and networks do you hope the Academy might help you build a stronger connection with?*How do you anticipate your participation will strengthen the statewide equity and justice community?*The Academy explicitly focuses on building Fellows’ capacity for engaging in anti-racism and anti-oppression work. How would you briefly describe what you would like to gain from the Academy that would further your own personal development in this area?*(Optional) Are there any known or anticipated challenges you might have with virtual learning? What resources would meaningfully support you through our program?(Optional) Please describe how your perspective and/or lived experience might contribute to the development of a cohort that represents the diversity of the many communities that intersect with the justice systems in Washington State.Additional DocumentsResume or Statement of Relevant Professional & Volunteer Experience*1-2 pagesAccepted file types: doc, docx, pdf.Employer/Sponsoring Organization Letter of SupportPlease visit the Application Instructions page to download an Employer/Sponsoring Organization Letter of Support form: https://justleadwa.org/leadership-academy/spring-2021-virtual-leadership-academy-application-instructions-information/. This letter is a required part of the completed application but you may have your sponsor email the form directly to info@justleadwa.org if needed. If you do not have an employer you may submit a letter of recommendation from a partner/peer organization.Accepted file types: doc, docx, pdf.EmailThis field is for validation purposes and should be left unchanged.
