I. Applicant Name and Contact Information

Organization Name

Mailing Address

City

State

Zip Code

Name of Primary Contact

Title

Email Address

Phone

II. Participant Information

The EDI Certification will engage two staff from each participating organization, ideally a senior leader and an emerging leader, in training, coaching sessions, and the in-person capstone presentation. Please identify your organization’s representatives.

Participant #1

Name of Participant

Title

Email Address

Phone Number

Years with Organization

Participant #2

Name of Participant

Title

Email Address

Phone Number

Years with Organization

III. Additional Information

Tell us about your organization’s mission, populations served, and services offered.

What is your organization’s annual revenue?

What has your organization done in the last 12-18 months to advance equity, diversity, and inclusion?

What prompted you to apply for this opportunity?

Provide a brief, high-level description of your initial thinking regarding your capstone project that focuses on improvements in at least one of the following areas:

Governance and LeadershipWorkforceCommunication and Language AssistanceContinuous Improvement, Accountability, and Community Engagement

Governance and Leadership

Workforce

Communication and Language Assistance

Continuous Improvement, Accountability, and Community Engagement

What outcomes would you like to see from achieving this certification?

Is there anything else you would like us to know?

Contact Information