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: July 24th, 2024 – ZOOM Kickoff call August 15th and 16th, 2024 – Opening Retreat September 11th, 2024 October 9th, 2024 November 13th, 2024 December 11th, 2024 January 8th, 2025 January 22nd, 2025 February 12th, 2025 March 12th, 2025 April 9th, 2025 May 14th, 2025 – Closing retreat May 22nd, 2025 – Graduation day Participation in planning a Class Day for the 2024-25 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
