Defining Leadership Application Form

Important Information

Please note: Attendance is required at all sessions, as each session builds upon the previous. Please ensure you are able to attend all program sessions before you apply.
Defining Leadership for Women: Fall 2022
September 22-23, October 20-21, November 17-18 and December 15-16 with a orientation on September 21 and an celebration on December 15.
Defining Leadership for Men: Spring 2023

February 2-3; March 2-3; March 30-31; April 27-28 with an orientation on February 1 and an celebration on April 27.

Series Applying For:

First Name

Preferred Name:

Last Name:

Title (i.e. Director of Marketing):

Company Name:

Business Address:

Business Address 2:

Business City:

Business State

Business ZIP/Postal Code

Business Phone:

Business Email:

Personal Email:

Business Fax:

Home Address:

Home City

Home State

Home ZIP/Postal Code:

Phone:

Cell Phone:

Defining Leadership begins with a Program Orientation Event and Closing Celebration for your supervisor and/or company sponsor to attend with you:

Who is authorizing/sponsoring your participation in the program?

First Name

Last Name

Title:

Email:

Who is your direct supervisor?

First Name

Last Name:

Title:

Email:

Are there any dietary restrictions or special accommodations you require?

Please provide your education history

College 1 Information:

Name:

Location (City, State):

Dates:

Degree (i.e. BA, BS, MBA)

Major:

Honors:

College 2 Information:

Name:

Location (City, State):

Dates:

Degree (i.e. BA, BS, MBA)

Major:

Honors:

Please provide a brief history of employment in chronological order, starting with your present position.

Organization 1 Information:

Name:

Dates:

Title:

Organization 2 Information:

Name:

Dates:

Title:

Organization 3 Information:

Name:

Dates:

Title:

Number of years in Supervisory Role:

Annual Compensation:

Please list any leadership or management development programs attended:

Please give a brief description of your career objectives:

Briefly explain why you want to participate in Defining Leadership:

The richness of the program is increased and learning enhanced when differences in individuals are present. What differences in perspective might you bring?

Have you ever attended an ICAN program?:

Please list ICAN programs you've attended:

Have you applied to ICAN's Defining Leadership program before?:

Please list community, civic, business, professional and social organizations in which you are an active member:

Please select those items in which you have an interest:

Being a mentorHaving a mentorHaving a professional coach

Complete the following questions ONLY if you work for a nonprofit organization with 50 employees or less.

Organization Name

Executive Director:

# of Employees:

Headquarters Location:

Who recommended you for this program?

What are your job accountabilities?:

How long have you been in this position?:

How did you hear about the ICAN Scholarship?:

Web Site:

NAM Member:

Operating Budget:

OFFER CODE

If you DO NOT wish for your picture to be used in ICAN promotional materials please check the box.

Should this program take place virtually, participants are required to use a computer or laptop with a camera (not a phone or ipad). The camera must be turned on for the specified time. By checking this box, I agree to these terms.

I Accept These Terms

I UNDERSTAND THAT ALL INFORMATION SUBMITTED WILL BE USED BY THE ICAN, INC. OFFICE AND THE SELECTION COMMITTEE ONLY. FACILITATORS PLEDGE ABSOLUTE CONFIDENTIALITY REGARDING INFORMATION CONTAINED IN ALL ASSESSMENTS. I UNDERSTAND THAT SUBMISSION OF THIS COMPLETED APPLICATION INDICATES THAT BOTH MY EMPLOYER AND I HAVE REVIEWED AND ACCEPT THE PROGRAM'S REQUIRED COMMITMENT OF TIME AND FINANCIAL RESOURCES. TUITION IS NONREFUNDABLE. SUBMISSION OF A COMPLETED APPLICATION INDICATES YOU ACCEPT THESE REFUND TERMS.

I Accept These Terms

Please note: Once your application is received, you will receive an email confirmation from ICAN. IF YOU DO NOT RECEIVE AN EMAIL WITHIN THE NEXT BUSINESS WEEK, please contact ICAN at ican@icanleaders.org to confirm receipt of your application.

Contact Information