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Application for Individual and Group Anti-Racist Leadership Coaching
Allow 10-15 minutes to complete. If you haven't already, please review the details at
http://evolutionaryworkplace.com/anti-racist-leadership-coaching
Note: Though not required, we encourage you to sign up in pairs or small groups of people that you interact with, or would like to interact with regularly, as it makes the work more fun and more relevant. Copy and paste this link to share with others:
https://forms.gle/tXTN2XkYJcfBsNTJ7
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Email
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Your email
We're delighted to meet you! We're Cleo Manago and Jill Nagle. What is your name?
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Your answer
Are you applying as an individual, or with others? If with others, please complete the next question. If as an individual, you can skip it. Note: If you are applying as a group, each member should fill out their own application.
Your answer
This is a three-part question: What is the nature of your group? For example, friends, colleagues on a marketing or health care team, and so on. How many in your group? Who is the main contact person for the group?
Your answer
How did you hear about the program? If a personal referral, who?
Your answer
Who else (if anyone) are you applying with? If no one currently, can you think of 1-3 people in your geographical area (or elsewhere) that you would like to do this work with?
Your answer
Telephone number?
Your answer
City, state or province, and country?
Your answer
Which age group are you in?
17 or younger (How old? Mention in any open space below.)
18-25
26-35
36-45
46-55
56-65
66-75
76 or older
Clear selection
If there a website or social media link that tells us more about you or your work that you're willing to share, please do so below.
Your answer
What time zone are you in?
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Your answer
What are you most passionate about leading or working on in the next 6 months to a year?
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Your answer
What is your experience leading the thing you are most passionate about? What have been your greatest successes and biggest challenges?
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Your answer
What do you anticipate will best support your efforts in 2022? (Check all that apply)
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Greater internal clarity of purpose
Coaches who both challenge and support me
Assistance with strategizing
Accountability, others invested in me accomplishing my goals
Better self-understanding of how I operate in challenging situations
Tools for navigating conflict
Additional time in my schedule
Financing
Clarity about how change happens
Understanding of the archetype(s) I embody and how to carve my unique path as a leader
Other:
Required
What if any personal or spiritual growth approaches, traditions, training programs or groups have you been part of in the past? Which of these has been most useful and why? Which has been least useful and why?
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Your answer
What attracts you to Jill and Cleo in particular?
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Your answer
All levels of experience are welcome. What is your level of experience with dismantling white supremacy?
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Bare-bones beginner
1
2
3
4
5
Veteran
What is your level of commitment to dismantling white supremacy?
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Minimal commitment
1
2
3
4
5
Maximum commitment
How do you see dismantling white supremacy as relevant to your leadership goals?
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Your answer
What is your ethnic background? Check all that apply. (Note: The program is geared specifically toward white-identifying people who generally receive white privilege, even if you have other ethnic heritage)
African (Black) -- please contact Cleo directly for one-on-one coaching at
drcleomanago@bmxnational.org
European (white)
Indian
Hispanic, Latino, Latina, or Latinx
Asian
Jewish
Catholic
Hindu
First Nations/Indigenous
Other:
Anything else you'd like to share about your background, and how it shapes who you are and how you feel in the world? (For example, gender identification, nationality, sexual orientation, physical ability, and so on).
Your answer
Any fears or concerns?
Your answer
In general, what are some good times for a 20-25 minute interview? All times below are Pacific time.
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Mondays 3 PM
Tuesdays 4 PM
Wednesdays 8 PM
Thursdays 2:30 PM
Other:
Required
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