HLD Application Step 1 of 6 16% Name* First Last CredentialsYears of Professional Experience*Business InformationPresent Employer*Type of Organization*Position*Business Mailing Address Street Address Address Line 2 City State MaineAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Business Phone*Business Phone Ext.Business Email Save and Continue Later Home InformationHome Mailing Address Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Mobile Phone*Home Email Additional InformationWould you prefer correspondence sent to your business or home email address?*BusinessHomeAny Dietary Restrictions?Emergency Contact Name First Last Emergency Contact Relationship*Emergency Contact Phone* Save and Continue Later Personal ProfilePlease attach a current resume or curriculum vitae*Strengths*The Program is committed to building share learning and trust among diverse leaders and across multiple interests. Please describe your unique strengths, background, attributes, or dimensions of diversity that you would bring to the class. Statement of Purpose*Please briefly describe what you hope to gain for yourself and/or your organization from the HLD course.Leadership*We are seeking individuals with a record of accomplishment and leadership within an organization or at the community, statewide, or professional association or society arenas. Please describe how you have, or are currently leading in Maine. Commitments*We are seeking candidates who are personally committed to improving the future of health and healthcare in Maine. Please describe how you have expressed this commitment in your work or volunteer life, including how much you demonstrate your passion for your work. Save and Continue Later Commitments HLD Program participants are expected to clear their schedules and attend every session. Full participation in the Outward Bound session is mandatory because of the focus on building the class learning community. Absences in any session affect the development of the group and diminish everyone's learning. While HLD staff will work with all participants to accommodate challenging schedules, we reserve the right to make graduation decisions contingent upon attendance.Each participant is also involved in a team practicum project which will require some work outside of class time . If selected I pledge to participate fully in in the leadership development experience and will honor the time commitments required. I am willing to make the following commitments if accepted as a HLD participant. Further, I understand that if I do not fulfill these commitments, my continued participation in the HLD program will be reviewed by the Hanley Center. I have read the HLD Materials and am able to commit the time necessary to attend all HLD program activities including all meetings and training sessions (On average, 2 days per month) I will be an active contributor to the HLD Program and participate in a team based learning community I will fulfill all learning projects required by the program I will participate in the evaluation of the HLD program I agree to allow my picture to be taken during the Program and alumni activities for Hanley Center publication or displays To be completed by the applicant:I have read the required conditions of the HLD program and I agree to all of the requirements described above Name* First Last Date* Save and Continue Later References Please list three references (if you are the CEO of your organization, one of the reference should be from your employer or sponsoring organization):Reference # 1 Name* First Last Reference # 1 Title*Reference # 1 Organization*Reference # 1 Phone*Reference # 1 Email* Reference #2 Name* First Last Reference #2 Title*Reference #2 Organization*Reference #2 Phone*Reference #2 Email* Reference #3 Name* First Last Reference #3 Title*Reference #3 Organization*Reference #3 Phone*Reference #3 Email* Save and Continue Later Organizational Commitment (if applicable) I have spoken to my organization regarding the HLD course. The below individual supports my participation, which includes allowing me time off from assigned duties to attend all sessions of the HLD course. Name of Supporting Individual First Last Title of Supporting IndividualPhone of Supporting IndividualEmail of Supporting Individual A non-refundable appication fee is required from all perspective applicants. You will be invoiced for this fee following the submission of this form. Checks can be mailed to: The Hanley Center 217 Commercial Street, Suite 406 Portland, ME 04101 Tuition Information Tuition for the Health Leadership Development 2019-2020 16-day leadership course is $5,900, and includes all meals, instructional materials and Outward Bound experience. It does not include travel and the cost of overnight accommodations other than Outward Bound. Applications received by April 6, 2016 are eligible for an 'Early Bird' discounted tuition of $5,700. Tuition assistance is available on a limited basis to ensure our ability to involve many dimensions of Maine’s health and healthcare community. If seeking tuition assistance, please request the Tuition Assistance Request Form by emailing Maggie Adelson at firstname.lastname@example.org. Tuition Assistance will be awarded based on need and availability of resources. Tuition Assistance requests are confidential. Upon acceptance into the program you will be invoiced a non-refundable deposit to equal to one third the cost of tuition which will hold your place in the class. Individuals receiving tuition assistance will be invoiced their minimum personal commitment ($250). Acceptance letters will be mailed by the end of June. The balance of tuition will be invoiced mid July and is due 15 days from date of invoice. No refunds can be made after the invoice date unless the reserved space in the program can be filled. Individual payment plans can be arranged. Up until August 28, a 50% credit toward the following year’s 16-day program will be issued for those who have a personal emergency requiring withdrawal from the program. Credits are non-refundable. Save and Continue Later This iframe contains the logic required to handle Ajax powered Gravity Forms.