September 2017 Thousand Currents Academy Application Details on the Academy, including eligibility, here: http://thousandcurrents.org/academy/ PERSONAL INFORMATION Question Title * 1. Applicant Name Last name: First name: Preferred name (if different): Question Title * 2. Organizational affiliation Organization Role (Optional) Secondary organizational affiliation (Optional) Secondary organizational affiliation role Question Title * 3. What is your gender identity? (Ex: woman, genderqueer, man). Question Title * 4. Preferred Pronoun(s) She He They Other (please specify) Question Title * 5. What is your age? 18-20 21-29 30-39 40-49 50-59 60 or older Question Title * 6. What is your ethnic and/or racial background? (Ex: Black, mixed Chinese and white, South Asian). Question Title * 7. Personal Contact Information Personal Address: * Personal Address 2: Personal City/Town: * Personal State: * -- 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 Personal ZIP: * Personal Email: * Personal Phone: * Question Title * 8. Work Contact Information Work Address: Work Address 2: Work City/Town: Work State: -- 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 Work ZIP: Work Email: Work Phone: Question Title * 9. Email & Phone - Preferred for Communication Personal Work Question Title * 10. Mailing Address - Preferred for Communication Personal Work Question Title * 11. Emergency Contact Name: Relation to You: Phone: Language Skills Question Title * 12. Language Question Title * 13. Proficiency Beginner Intermediate Advanced Fluent Question Title * 14. Language Question Title * 15. Proficiency Beginner Intermediate Advanced Fluent REFLECTION Brief Responses (100-250 words each) Question Title * 16. How were you informed of the Thousand Currents Academy? Question Title * 17. Please share why you would like to attend the Thousand Currents Academy. Question Title * 18. Please include your brief bio here and a photo below (JPG, high resolution) for the Thousand Currents Academy Welcome Packet, 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! Question Title * 19. Upload your photo here. DOCX, DOC, JPG, GIF, JPEG, PDF, PNG file types only. Choose File Choose File No file chosen Remove File Upload your photo here. ACCOMMODATIONS, PREFERENCES & NEEDS Question Title * 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. Question Title * 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. Question Title * 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. Question Title * 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. Thank you! We will be in touch in mid-July