March 2018 Thousand Currents Academy Application

Details on the Academy, including eligibility, here: http://thousandcurrents.org/academy/

Deadline to apply has been extended to January 23rd, 2018

PERSONAL INFORMATION

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* 1. Applicant Name

Last name:

First name:

Preferred name (if different):

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* 2. Organizational affiliation

Organization

Role

(Optional) Secondary organizational affiliation

(Optional) Secondary organizational affiliation role

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* 3. What is your gender identity? (Ex: woman, genderqueer, man).

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* 4. Preferred Pronoun(s)

She

They

Other (please specify)

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* 5. What is your age?

18-20

21-29

30-39

40-49

50-59

60 or older

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* 6. What is your ethnic and/or racial background? (Ex: Black, mixed Chinese and white, South Asian).

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* 7. Personal Contact Information

Personal Address: *

Personal Address 2:

Personal City/Town: *

Personal State: *

Personal ZIP: *

Personal Email: *

Personal Phone: *

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* 8. Work Contact Information

Work Address:

Work Address 2:

Work City/Town:

Work State:

Work ZIP:

Work Email:

Work Phone:

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* 9. Email & Phone - Preferred for Communication

Personal

Work

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* 10. Mailing Address - Preferred for Communication

Personal

Work

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* 11. Emergency Contact

Name:

Relation to You:

Phone:

Language Skills

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* 12. Language

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* 13. Proficiency

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* 14. Language

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* 15. Proficiency

REFLECTION

Brief Responses (100-250 words each)

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* 16. How were you informed of the Thousand Currents Academy?

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* 17. Please share why you would like to attend the Thousand Currents Academy.

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* 18. Please include your brief bio (150 words) here and a photo below (JPG, high resolution) for the Thousand Currents Academy Orientation Guide, which we send to all participants in the weeks prior to the Academy. If you would prefer to not share your photo and/or bio with other participants, please note that here and we will take care not publish or share it beyond Thousand Currents staff and faculty; however please still include here for our internal purposes of knowing a bit more about who you are!

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* 19. Upload your photo here.

DOCX, DOC, JPG, GIF, JPEG, PDF, PNG file types only.

Choose File

ACCOMMODATIONS, PREFERENCES & NEEDS

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* 20. Dietary Restrictions: Please let us know any special considerations we should be aware of when arranging your meals and specify if they are allergy-related, religious or cultural practices, or other personal dietary choices.

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* 21. Accommodations: Please let us know any special considerations we should be aware of when arranging your sleeping quarters, activity spaces, and curriculum materials. This includes needs related to vision and hearing, mobility, and any other ability or health related requirements. This also includes family needs like on-site childcare.
Note: Accommodations are shared, 2-4 people in a room.

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* 22. Do you have preferences for a roommate in terms of similar gender or other identities, or a specific individual you know is also applying to the Academy? Please specify below.

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* 23. What fee range do you anticipate you will fall in, if accepted to the Academy?

We ask so we can anticipate costs and revenue, to do our best to ensure as many participants as possible who need subsidized fees or payment plans can access them.

Please refer to http://thousandcurrents.org/academy/apply/ for guidance on which fee range is appropriate for you.

I anticipate paying in the Full-cost fee range ($2,000-$3,000)

I anticipate paying the Subsidized fee range ($1,500-$2,000)

I anticipate paying in the Solidarity fee range ($3,000-$5,000)

I anticipate a lump sum of $1,500 being a barrier to my participation. Please contact me about payment plans.

Please specify details about what would help make the Academy financially accessible to you. For example, "I could pay $1,500 in 4 installments over the course of 6 months." The more information we have, the more we can do our best to work with you to make the Academy affordable.