March 2015 IDEX Academy Application REMINDER: Please don't forget to send your resume/CV with a list of two references (names, titles, contact information) with subject line "Application for IDEX Academy" to Rajiv Khanna: rajiv@idex.org. PERSONAL INFORMATION Question Title * Applicant Name Family Name: Given Name: Preferred Name (if different): Question Title * Gender Male Female Other (please specify) Question Title * Preferred Pronoun(s) He She They Other (please specify) Question Title * 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 * 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 * Email & Phone - Preferred for Communication Personal Work Question Title * Mailing Address - Preferred for Communication Personal Work Question Title * Emergency Contact Name: Relation to You: Phone: Question Title * Dietary Restrictions: Please let us know about 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 * Physical Accommodations: Please let us know about special considerations we should be aware of when arranging your transportation, sleeping quarters, activity spaces, and curriculum materials including vision and hearing needs, mobility needs, and any other ability or health related requirements. Language Skills Question Title * Language Question Title * Language Question Title * Language Question Title * Proficiency Beginner Intermediate Advanced Fluent Question Title * Proficiency Beginner Intermediate Advanced Fluent Question Title * Proficiency Beginner Intermediate Advanced Fluent REFLECTION For this section, please refer to the IDEX Theory of Change. Please take a moment to peruse the Theory of Change, as it will form the basis of the IDEX Academy Curriculum. Brief Responses (100-250 words each) Question Title * 1. What aspect of the IDEX Theory of Change do you think holds the greatest learning potential for you and/or your organization? Question Title * 2. Please share with us how you were informed about the IDEX Academy and what you expect to learn. REMINDER: Please don't forget to send your resume/CV with a list of two references (name, title, contact information) with subject line "Application for IDEX Academy" to Rajiv Khanna: rajiv@idex.org. Done