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* 1. Your information

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* 2. Employment Information

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* 4. Do you work full time for this agency?

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* 5. Supervisor's name

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* 6. Supervisor's email

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* 7. Do you currently hold a Registered Sanitarian/Registered Environmental Health Specialist credential?

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* 8. What agency issues your RS/REHS credential?

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* 9. Are you a current member of NEHA?

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* 11. Staff size of workforce

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* 12. Job title

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* 13. Job responsibilities

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* 14. Years of environmental health experience

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* 15. Attendance at the NEHA's 2024 Annual Educational Conference (AEC) is mandatory.  The 2024 AEC location will be Pittsburgh, PA.   Can you commit to attending? 

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* 16. Please list any other leadership training programs you have attended.

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* 17. What areas of environmental health have you worked in? (Check all that apply)

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* 18. Please list all credentials, certifications, and/or degrees

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* 19. A one-page letter of support to participate in this program from your department head or immediate supervisor is required. Either upload a copy here or email a PDF copy to ehlaprogram@neha.org.

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* 20. Please provide a personal statement, so we can learn more about you.  Your statement should be no more than 500 words and include what you desire, what you expect to gain, and what it means personally to participate in NEHA’s Leadership Academy.  Also, include your leadership skills, career aspirations, and any other information you believe would make you a good candidate.

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* 21. The tuition for this program is $2,000.  Will your employer be able to provide financial assistance for you to attend program?

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* 22. If you would like to be considered for a need-based scholarship, please describe why support is needed.

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* 23. By typing your full name below, I hereby certify that the above information is complete and accurate. I also fully understand and agree to the following:


• Attend all online training modules of NEHA’s leadership program, which requires a commitment of one year. The modules will be once a month and last 4 hours.

• Attend all modules associated with the leadership academy at NEHA’s 2024 Annual Educational Conference. Please be aware that the cost of AEC registration and any travel or lodging are not included in the program fee.

• Complete all required readings before the monthly modules and/or submit course assignments on time.

• Show up on time to all online and in-person program modules, ready to learn.

• Receive a written letter of support from my department head to be a part of this leadership academy. Written letter of support must be submitted with the application.

• Participate in group settings when the program assignment demands such.

• Engage in dialogue with fellow program participants and instructor to enrich the program.

• Provide feedback on program content and material to the leadership program’s administrative team to help improve the program.

• Agree to participate in either one-on-one or group sessions with a mentor for a set amount of time, once a month.

• Work on a year-end project which must benefit either your organization, community served, or the EH workforce. 

• Complete all post module and program evaluations.

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