Leadership Southern Indiana DISCOVER Application Step 1 of 4 25% Applicant InformationName* First Last GenderMaleFemaleGender FluidNon-BinaryOther/Prefer not to answerPreferred Pronouns He/him She/her They/them Prefer not to answer Preferred Name* Home Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Personal Email Address* Cell Phone*Please Upload a Headshot* Drop files here or Select files Max. file size: 50 MB. Please be sure that your headshot image is titled with your name.Employment InformationEmployer Name* Job Title* Work Email Address* Work Phone Number*Work Address* Street Address City State / Province / Region ZIP / Postal Code Employer Knowledge Disclosure Please mark if your employer is aware that you are applying Please mark if your employer has consented to be billed for the program Which email do you prefer to have us contact?* Personal Work Both T-Shirt Size* Dietary Restrictions* What are you looking to gain from this experience?*Reference #1 - Name & Phone* Reference #2 - Name & Phone* How did you hear about the program?* Payment Options – We understand that not everyone has an employer paying for their tuition. To that end our board of directors has approved a payment plan option. Once accepted into the program you may chose a 4-payment option, with ¼ of the payment due in the following months (July, October, January & March). Note: Payment is not required until you have been accepted into the program. DISCOVER program participants will be announced in June. Check here to request financial assistance: I would like to be contacted about financial assistance There are five KEY components to your Leadership Southern Indiana DISCOVER Program experience: Opening Retreat- Aug 24th-Aug 25th (Overnight) History Day- Sept 13th Scott County Day- Oct 11th Economy and Workforce Day – Nov 8th Education Day – Nov 29th Diversity Equity and Inclusion Day (tentative) – Dec 13th Government Day (tentative) – Jan 10th SIMSOC Day – Feb 14th Healthy Communities Day – Mar 14th Tourism Day – April 10th Closing Retreat – May 8th DISCOVER ELEVATE Graduation – May 16th Breakfast Series for 23-24 dates Feb 6th and Mar 5th Participation in planning a Class Day for the 2023-24 DISCOVER Program - Dates to be determined by DISCOVER Committee. This will be the year following your graduation. Accept the mission of Leadership Southern Indiana: To engage, develop and mobilize regional leaders who will serve and transform our community. Thank you for applying for Leadership Southern Indiana’s DISCOVER Program! Δ
