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APPLICATION - For Lideramos Cohort 1 (September 2023 - February 2024)

APPLICATION DEADLINE: Extended beyond May 2023 until cohort of 25 is full.
Open to adults who are 25 and older, as of September 2023, from all sectors in the Quad Cities and surrounding area who identify as Latino, Latina, or Latinx.
DIRECTIONS. Before you begin, please visit/click https://lideramos.org/programs/lideramos-quad-cities/ to download & review detailed session descriptions & required dates. Respondents can return and finish or change their answers, only before but not after they click 'Done' to complete the survey (use the same computer). Suggestion: Review the full survey/application and type short essay responses separately then copy and paste them into your application.
CONTACT INFORMATION

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* 1. First Name:

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* 2. Middle Name:

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* 3. Last Name:

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* 4. Preferred First Name/Nickname:

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* 5. Home Street Address:

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* 6. Home City:

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* 7. Home State:

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* 8. Home Zip:

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* 9. Personal Cell Phone (For session changes or update messages):

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* 10. Work Cell Phone (For session changes or update messages):

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* 11. Personal E-mail:

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* 12. Work email:

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* 13. Age:

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* 14. Birthdate:

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* 15. Which of the following options most closely aligns with your gender?

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* 16. Are you of Spanish, Hispanic or Latino origin or descent?

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* 17. Multi-ethnic/Other? (If yes, please specify)

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* 18. Which race best describes you? (Please choose only one.)

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* 19. What is the last grade of school you completed?

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* 20. In which branch (or branches) of the United States military have you served? (Check all that apply)

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* 21. Name of Company or Organization of Employment:

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* 22. Work City:

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* 23. Work State:

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* 24. Work Zip Code:

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* 25. Position or Title:

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* 26. Which of the following best describes your current job level?

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* 27. What do you hope to gain during participation in Lideramos QC?

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* 28. What do you hope to contribute during participation in Lideramos QC?

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* 29. LEADERSHIP ACTIVITIES: Leadership exists in many forms in the community. Please list and describe leadership experiences of any kind and place, in order of importance to you, where you played an important role.

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* 30. COMMUNITY VISION: What is your vision for your community, how can it be improved, and the role you can play?

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* 31. LEADERSHIP EDUCATION COURSES OR TRAINING: In what ways have you continued to develop your leadership abilities?

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* 32. COMMITMENT TO SUPPORT INVOLVEMENT IN LIDERAMOS QC: Are you willing to attend and be actively involved in all Lideramos QC Cohort training sessions? (See full schedule with dates and times)

TUITION: The LIDERAMOS QC Program regular rate is $1,000, payable after acceptance, in full or in reoccurring partial payments. Scholarships will be available according to need. You may also seek employer sponsorship.

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* 33. Sponsorship amount?

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* 34. In 1 Full payment?

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* 35. Or Number of Partial Payments?

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* 36. In what individual amounts?

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* 37. Participant Payment Amount?

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* 38. In 1 Full payment? 

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* 39. Or number of Partial Payments 

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* 40. In what individual amounts?

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* 41. If needed, scholarship request amount?

For further information, Contact: Joe Moralez or Alfred Ramirez, at lideramosqc@gmail.com 
 
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