FOCUS Impact Fellows Application Form – FOCUS

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FOCUS Impact Fellows 2022-23 Application

Name*
First Last
Preferred Name
Home Address
Street Address Address Line 2 City State ZIP Code
Work Address
Street Address Address Line 2 City State ZIP Code
Preferred Mailing Address
- Home
- Work
Preferred Phone
Phone Type
- Home
- Work
- Mobile
Email*
Number of Years in the St. Louis region
Are you a graduate of a FOCUS St. Louis program?
- Yes
- No
If yes, which program(s)?
- Youth Leadership St. Louis
- Emerging Leaders
- Women In Leadership
- Coro Fellowship in Public Affairs
- Experience St. Louis
- Leadership St. Louis
- Other
Please list any leadership programs you have participated in, besides FOCUS programs. Include dates.
Demographics
The following questions help us to measure the diversity of our class and our outreach efforts.
Date of Birth (in month/day/year format)
MM slash DD slash YYYY
Gender
- Male
- Female
- Prefer not to say
- Not listed
If not listed, please specify:
Which categories describe you?
Select all that apply.
- White/Caucasian
- Black or African American
- Hispanic, Latino or Spanish origin
- Asian
- American Indian or Alaska Native
- Middle Eastern or North African
- Native Hawaiian or Pacific Islander
- Some other race, ethnicity or origin
If other, please specify:
Select county of residence.
In which sector do you work?
- Business/Corporate
- Nonprofit
- Government/Public Service
- Education
- Health Care
- Labor
- Entrepreneur
- Legal
- Volunteer
- Other
If you checked other, please specify.
Employment
Current Title/Position
Current Employer/Organization
Describe your major responsibilities:
Dates of employment - To/From:
Please list your previous employment, beginning with your most recent position.
I. Dates - To/From
I. Title/Position
I. Employer
I. Major Responsibilities
II. Dates - To/From
II. Title/Position
II. Employer
II. Major Responsibilities
III. Dates - To/From
III. Title/Position
III. Employer
III. Major Responsibilities
Community/Civic Involvement
Please list no more than 5 civic/community organizations that you are or have been a part of, including dates.
Education
Degrees/Certifications
Personal Perspective
What specific skills, knowledge or experience would you bring to this class of Impact Fellows?
What personal or professional outcomes are you hoping to achieve through participation?
How did you hear about FOCUS Impact Fellows?
Subscribe
- Yes, I'd like to receive emails about upcoming FOCUS events, civic engagement opportunities and programs.
Before hitting Submit, please review the following requirements and check that you agree to each of them.*
- My employer supports my participation in the Impact Fellows program and all program days.
- I am willing to make the September-May commitment for the Impact Fellows program.
- I am aware that my absenteeism will result in my being dropped from the program.
- I understand that all program fees are non-refundable.

Save and Continue Later

“I would encourage anyone who is looking for a way to engage and move our community forward to apply for this program.”

Stephanie Regagnon

CEO, FieldWatch
FOCUS Impact Fellows 2016, Leadership St. Louis 2012-2013

Leadership For a Thriving Region

Leadership For
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© 2021 FOCUS St. Louis®

815 Olive Street, #110 • St. Louis, MO 63101

phone: (314) 622-1250

email: info@focus-stl.org

© 2017 FOCUS St. Louis®

815 Olive Street, #110

St. Louis, MO 63101

phone: 314.622.1250

email: focus-stl.org

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