The LGBT Inclusion Project Application Form Question Title Thank you for your interest in the LGBTQ Inclusion Project in collaboration with Keshet. Please fill out the following application in its entirety by October 19th, 2015. We will notify institutions if they have been accepted by October 30th, 2015.WHAT COMMITMENT MUST AN ORGANIZATION MAKE TO PARTICIPATE?- Enter the program committed to embarking on a year of taking concrete, realistic steps toward a more LGBTQ-inclusive institution- Complete a self-guided Institutional Self-Assessment prior to the Kick-Off Summit.- Send a team of 3 people, including at least one top level leader, and one teen voice, to participate in the day-long Leadership Summit.- As part of the day-long training, work with your team to complete an Action Plan for making concrete, realistic change for greater LGBT inclusion over the course of the next 12 months.- Appoint a Team Liaison to be in direct communication with The Jewish Education Project and Keshet staff- Participate in two additional in-person gatherings throughout the remainder of the year.- Your team will meet with your Coach 6 times over the next 12 months.- Your team will participate in three peer reflection conference calls over the next 12 months.- Time required for fulfillment of Action Plan will vary depending on the nature of the Action Plan strategies selected. We estimate that a team will need to spend at least 10 hours per month to enact meaningful changes.- We strongly encourage participating institutions to create an ongoing Inclusion Task Force to guide this work.- A commitment of only $180.00 per team of 2-4 people for the year-long program.The LGBTQ Inclusion Project is made possible by generous funding from the Jim Joseph Foundation and Keshet.If you have questions, please contact Les Skolnik at lskolnik@JewishEdProject.org or 646.472.5326. Question Title * 1. Jewish Institutional Information Organization Name * Address * Address 2 City/Town * State/Province * -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code * Country * Phone Number * Website * Question Title * 2. Type of Institution (Check all that apply). Synagogue Youth Group Hebrew High School Jewish Federation or Beneficiary Agency Jewish Community Center Jewish Day School Foundation Jewish Agency Summer Camp Youth Movement Other Question Title * 3. Which best describes your institution's affiliation with the Jewish community? Conservative Humanistic Orthodox Pluralistic Reconstructionist Reform Secular Unaffiliated Zionist Other (please specify) Question Title * 4. Approximately how many teens would you describe as "highly engaged" in your program? Question Title * 5. Approximately how many teens would you describe as "somewhat engaged" in your program? Question Title * 6. “Approximately how many potential teens do you have in your community who are currently “under-engaged” or “not engaged” in your program?” Question Title * 7. Why are you interested in participating in the LGBTQ Inclusion Project? Please be as specific as possible. Question Title * 8. What are your institution's values that lead you to believe that you will be successful at creating meaningful change in LGBTQ Inclusion? Question Title * 9. Which 2-4 people from your organization will form the core professional and volunteer leaders dedicated to this initiative? Team members you should consider may be clergy, professional or executive staff, lay leadership and teens! Question Title * 10. Do you have any questions for us? Anything else we should know? Question Title * 11. Primary Organizational Point of Contact Name Title Email Address Phone Number Question Title * 12. This person is a Staff Member Volunteer/Lay Leader Other (please specify) Question Title * 13. Role Member Clergy Board Member Education Director Youth Professional Lay Leader/Volunteer Teen Headmaster/Principal Other (please specify) Question Title * 14. Commitment:Our institution is committed to full participation in the LGBTQ Inclusion Project from The Jewish Education Project in collaboration with Keshet. We are aware of the scope of our participation and agree to participate fully and completely in the learning, coaching, reflection, and documentation of the program.Signature/Date Done
