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Application for Sabbatical Program for Black & Indigenous Executive Leaders
Questions? Email Jason Boyd at jboyd@blackmc.org
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* Indicates required question
Email
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Your email
President/Executive Director:
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Your answer
Organization Name:
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Your answer
Street Address:
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Your answer
City/Town:
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Your answer
State:
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Your answer
Zipcode:
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Your answer
Phone:
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Your answer
Website:
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Your answer
Do you have 501 (c) (3) status?
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Yes
No
If YES, please provide EIN:
Your answer
If NO, please provide the name, EIN number, and contact information for your host organization:
Your answer
Fiscal Year Start Date (MM/DD/YYYY):
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MM
/
DD
/
YYYY
Organization Budget Amount:
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Your answer
Please list your board members
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Your answer
Please share name and contact information of your organization's board chair/president
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Your answer
Total # of Staff:
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Your answer
Description of Organization:
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Please tell us about your organization. Describe its mission, vision, values, & description of programs. (500 words or less).
Your answer
Organization demographics
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Please check all that apply. (For reference, BIPOC refers to Black, Indigenous, and People of Color)
Executive Director identifies as Black and/or Indigenous
51% or more of executive level staff identify as BIPOC
51% or more of board identify as BIPOC
None of the above
Other:
Required
Applicant, what is your title:
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Your answer
Applicant, how long have you been in executive leadership at your organization?
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Your answer
Applicant, how do you describe your race, ethnicity, and nationality?
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Your answer
Description of your request
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Please give us more information about your request. Why you are planning a sabbatical now? For how long do you intend to be on sabbatical? (500 words or less)
Your answer
We are committed to working with organizations to ensure that they have adequate support while the applicant is on sabbatical. Give us a sense of what kind of support your organization might need while you are away.
Click here for an example of different types of organizational support
Your answer
How did you learn about the sabbatical program?
*
Your answer
A copy of your responses will be emailed to the address you provided.
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