Participant Application
Cross Cultural Leadership Retreat
October 26-28, 2007

Thank you for your interest in the Cross Cultural Leadership Retreat.

To apply, please fill out the form below. The last section of the form asks a series of questions which may require some thought. We recommend reviewing the form to familiarize yourself before completing. After submitting the form, you will be asked to download a program participation release form which must be returned to the Center for Student Leadership & Involvement before your application is considered complete. Applications will be accepted through Friday, September 28, 2007 or all of the available spaces are filled.

(*denotes a required field)

Part I
Name*
Name as you prefer it on your nametag
Campus/Local Address*
Local Telephone Number*
Cell Phone Number (optional)
Email Address*
IM Screen Name
May we include your contact information on a roster to be distributed to all participants ? * Yes No
Please tell us about yourself. *
Do you identify as

Male Female Transgender

Other

This information is used for rooming assignments. Since this application is not confidential and may be viewed by a committee participant selection. Students who do not identify as male or female may contact Kelly Stevens in the Center for Student Leadership & Involvement in order to address rooming assignments and to maintain confidentiality.

Class Standing*

School (Check all that Apply)*
First Year
Sophomore
Junior
Senior
Graduate Student 		Business
Communications
Humanities & Sciences
Health Sciences & Human Performance
Inderdisciplinary & International Studies
Music
Major*
Please help us prepare for your participation
Emergency Contact Name*
Relationship*
Telephone Number *
Are there any special needs as defined by the Americans with Disabiltiies Act (ADA)? Information provided here is intended to assist facilitators to appropriately prepare for participation.*

No Yes
If yes, please explain
Dietary Concerns
None Vegetarian Vegan Kosher

Food Allergies, please explain

Other:
Part II. Please respond to the following questions. *
1. Why do you wish to attend the Cross Cultural Leadership Retreat?
2. How does diversity impact the role of a leader?
3. This last question is used by the faciliators to gauge the dynamic of the selected group in preparation for the retreat's individual sessions. As the retreat is designed around voluntary self-disclosure, the faciliators will not share these reposponses with the other participants.

If I had to describe myself in terms of my heritage and cultural background or experience, I would say I am:
Ethnic or Racial Identity
Sexual Orientation
Socioeconomic Status
Religion/Spiritual Identity
Two other aspects of your culture which you wish to share

   

 

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