PLEASE NOTE THAT THE INFORMATION FROM THIS APPLICATION WILL NOT BE SHARED OR LINKED TO YOUR COMPANY OR EMPLOYER.  IT WILL BE USED FOR STATISTICAL PURPOSES ONLY.

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* 1. Please indicate the full name of your organization. (no acronyms please)

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* 2. The location of your organization is

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* 3. Type of Organization

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* 4. Applicant information

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* 5. How do you identify?

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* 6. What pronouns do you use?

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* 7. Please enter the name of the co-applicant from your organization.

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* 8. Please give us your supervisor's name, email and phone number

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* 9. Number of Employees at your organization.

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* 10. Employee Racial Identity of your organization by percentage.

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* 11. In thinking about your organization's level of comfort and understanding with the following topics where would you position it?

  Uncomfortable - needs more awareness and education Neither comfortable or uncomfortable - neutral Comfortable - employees are aware and educated on this identity
Ability
Ageism / Adultism
Body Size
Class
Gender
Race
Religion
Sex
Sexual Orientation

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* 12. In thinking about your personal level of knowledge with the following topics where would you position yourself?

  Need more information Solid understanding and more to learn Solid understanding and I could teach about the topic None of these
Ability
Ageism / Adultism
Body Size
Class
Gender
Race
Religion
Sex
Sexual Orientation

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* 13. We want to hear your story. What drew you to this program? How can this program benefit you the most?

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* 14. What specifically would you like to learn more about regarding diversity, equity and inclusion (DEI)?

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* 15. Please share one or more incidents that your organization has dealt with related to DEI, with regard to any of the 9 identities: ability, age, body size, class, gender, race, religion, sex, or sexual orientation.

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* 16. Are there any situations or topics with regard to DEI that you are uncertain how to respond or handle?

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* 17. What additional knowledge, resources or training would you be most interested in for professional development?

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* 18. What additional information would be important for NCCJ to know about you and/or your organization?

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* 19. Is there anything we didn't ask you that you would like to comment on?

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* 20. Do you foresee any conflicts or challenges with any of the dates?

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* 21. If you are accepted into the program, do you have any allergies - food allergies or other? If yes, please list.

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* 22. If you are accepted into the program, do you need any accommodations for in person or on ZOOM? (So we can prepare in advance.)

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