OFFICE FOR INCLUSION, DIVERSITYAND EQUAL OPPORTUNITY Train the Champion Program Class of 2016 APPLICATION FORM Deadline Date: December 28, 2015 Please return the application to janetta.hammock@case.edu Please attach your most recent curriculum vitae or resume Full Name: ____________________________________________________________________ Preferred Name: ________________________________________________________________ Position/Title: __________________________________________________________________ School/Department: _____________________________________________________________ Number of Years at Case Western Reserve: __________________________________________ Mail Location: _________________________________________________________________ Phone Number: ________________________________________________________________ E-mail Address________________________________________________________________ Direct Supervisor: ______________________________________________________________ Discuss your interest in Train the Champion and what you hope to gain from the program. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ List any campus/community involvements, or roles in leadership, including previous or current: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Supervisor Information: My direct supervisor is aware of the Office for Inclusion, Diversity and Equal Opportunity’s Train and Champion Program and supports my full participation in the program. Direct Supervisor’s Signature ________________________________________________ Date __________________ Dates of Participation In order to successfully complete the Train the Champion Program, participates are permitted to miss only two sessions. Unless otherwise noted, all sessions are held 11:30 a.m. to 1:00 p.m. (excluding the first and last sessions). Tentatively, the sessions will be held on the third Tuesdays of each month beginning in January through November with the January meeting being held all day and the last session in November lasting for two hours. Tentative dates for 2016 are as follows: January 19, 2016 (all day) - MANDATORY ATTENDANCE February 16, 2016 March 15, 2016 April 19, 2016 May 17, 2016 June 21, 2015 August 16, 2016 September 20, 2016 October 18, 2016 November 15, 2016 (2 hour session) Participant’s Signature: ________________________________ Date: ___________________ In an effort to create an inclusive and diverse group of participants for the Train the Champion Program, the Office for Inclusion, Diversity and Equal Opportunity requests that applicants complete the OPTIONAL demographic information below. Do not provide this page to your supervisor when requesting your supervisor’s signature on the prior page. The Office for Inclusion, Diversity and Equal Opportunity will use the following data solely for purposes related to the Train the Champion Program. The following questions are OPTIONAL. If applicants choose not to disclose the following information, they will still receive equal treatment and consideration for the Train the Champion Program. How would you self-identify in the following categories: Race: Ethnicity: Religion: Gender: Nationality: What is your date of birth? Do you have a disability? ( ) Yes ( ) No Case Western Reserve University does not discriminate in recruitment, employment, or policy administration on the basis of race, religion, age, sex, color, disability, sexual orientation, national or ethnic origin, political affiliation, or status as disabled veteran or veteran of the Vietnam era.