Step I: Summer Institute Applicaiton

Thank you for your interest in the 2008 Summer Institute. This is Step I of the six step application process. If you have any questions, please contact Katrina Lamberto at klamberto@nccwps.org or 919-508-2308.

The application deadline is May 12, 2008.

A. Personal Information

First Name:	MI:
Last Name:
Address:
City/Sate/Zip:
E-mail:
Day Phone:
Eve. Phone:
Cell Phone:
Age:	(for reporting purposes only)

If you speak any languages other than English, please list them here:

Where did you hear about the Summer Institute?

If you heard about the Summer Institute through NCCWPS outreach efforts, check all that apply:
A flyer A news story NCCWPS website NCCWPS presentation

If you heard about NCCWPS through a personal contact, please explain:

I know a board member or SI graduate. Name:
I was referred to NCCWPS by
I heard about NCCWPS through another community organization:

Other. Please explain:

If you have previously enrolled in a NCCWPS program, please tell us

Which program:

Where:

When:

B. Summer Information

If the address above is not where we will be able to reach you during the summer, please complete this section:

Dates Effective:	From To
Address:
City/Sate/Zip:
Day Phone:
Eve. Phone:

C. Voter Information (for reporting purposes)

Length of NC Residency: years

Are you registered to vote? Yes No

Your county of residence:

Please provide the following election districts. This information is available on your voter registration form or from your county Board of Elections.

Congressional District:
NC Senate District:
NC House District:
County Commissioner District
Board of Education District:

What is your party affiliation? (for reporting purposes only)

Other:

D. Other Information

NCCWPS strives to support a diverse group of participants. We work hard to find ways to accommodate the needs of our program participants.

The Summer Institute is a residential program. Do you have any accessibility needs related to a disability or dietary requirements that we can accommodate? Yes No

If yes, please describe:

The cost of the SI is $1000. Financial assistance is available for up to 80% of tuition. Do you expect to apply for tuition assistance? Yes No

Privacy Policy

The information you provide on this application to the NC Center for the Women in Public Service will not be shared with any other group. The Center staff will use the information to evaluate your application, to contact you regarding upcoming events, and to keep you posted on training and mentoring opportunities offered by the Center.