Executive Roundtable Application Please answer the following questions to your best ability. Question Title * 1. Please provide your contact information Name * Organization * Position Title * Address City/Town * ZIP/Postal Code * Email Address * Phone Number * Question Title * 2. Which of the following best describes your organization? health/wellness education/research environment/animals arts/culture/humanities human/social services international religious civic engagement/ social justice trade other Please specify (for trade or other) Question Title * 3. Which of the following categories apply to you? An association CEO/ED Nonprofit CEO/ED Association Executive (please specify in "other" box below) Currently supported by/partner of Vitalyst Health Initiative Supported by/partner of Vitalyst Health Initiative in the past In conversation with Vitalyst Health Initiative for their support/partnership Other (please specify) Question Title * 4. If your organization is an Association, how many member organizations do you have? Question Title * 5. If you are an Association, what is your geographical reach? Local Statewide National International Question Title * 6. In what range does your organizational budget fall? Under $500,000 $500,000-$4,000,000 $4,000,001-$10,000,000 $10,000,001-$20,000,000 Above $20,000,000 Question Title * 7. What is the mission of your organization? Question Title * 8. Do you report directly to a board of directors? Yes No Question Title * 9. If you don't report directly to a board, please describe your relationship to the board. Question Title * 10. About how many employees work at your organization? Question Title * 11. How many employees directly report to you? Question Title * 12. How do you self-identify? American Indian or Alaskan Native Asian American Black/African American Hispanic/Latino Native Hawaiian or other Pacific Islander White/Caucasian Multi-ethnic/Multi-racial Would rather not say Other (please specify) Question Title * 13. How many years have you been in your position? Question Title * 14. When you think of your current organizational context, what 3 things would you most like to get help with? 1- 2- 3- Question Title * 15. What about your work most feeds your energy? Question Title * 16. On a scale of 1-10 (10 being the best), how would you rate your work/life balance? Question Title * 17. When you think of yourself as a whole organizational and community leader, what 3 areas would you most like to develop in yourself? 1- 2- 3- Question Title * 18. If you were at the top of your game as a leader, what would that look and feel like? Question Title * 19. Why are you interested in participating in a Roundtable? What do you hope to get out of it? Question Title * 20. Roundtable meetings will rotate between member organizations. Are you willing to host, which means provide a location and some snacks/refreshments, at least once during the year? Yes No Question Title * 21. Are you willing to commit to participating in the Roundtable for a year (10 half-day meetings a year)? Yes No Question Title * 22. Would you be interested in finding out more about any of the following? Executive Coaching (gives an opportunity to work deeper in a one-on-one relationship) A half- or full-day strategizing session (an opportunity to delve quickly into an issue with a coach) On-demand coaching (you get one-on-one coaching only when you need it) Six-month leadership development group coaching program (build your leadership skills with the support of a facilitator/coach and a small group of other leaders) Question Title * 23. What else, if anything, would you like for me to take into consideration? Done
