Apply Now FOCUS Impact Fellows 2018-19 Application Name* First Last Nickname (if preferred)Home Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Work Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Preferred Mailing AddressHomeWorkPreferred PhonePhone TypeHomeWorkMobileEmail* Number of Years in the St. Louis regionAre you a graduate of a FOCUS St. Louis program?YesNoIf yes, which program(s)? Youth Leadership St. Louis Emerging Leaders Coro 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.DemographicsThe following questions help us to measure the diversity of our class and our outreach efforts.Date of Birth (in month/day/year format) SexMaleFemaleIntersexPrefer not to sayWhich 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.St. Louis City (MO)St. Louis County (MO)St. Charles (MO)Jefferson (MO)Lincoln (MO)Warren (MO)Franklin (MO)Madison (IL)St. Clair (IL)Monroe (IL)Calhoun (IL)Macoupin (IL)Jersey (IL)Bond (IL)Clinton (IL)OtherIn which sector do you work?Business/CorporateNonprofitGovernment/Public ServiceEducationHealth CareLaborEntrepreneurLegalVolunteerOtherIf you checked other, please specify.EmploymentCurrent Title/PositionCurrent Employer/OrganizationDescribe your major responsibilities:Dates of employment - To/From:Please list your previous employment, beginning with your most recent position.I. Dates - To/FromI. Title/PositionI. EmployerI. Major ResponsibilitiesII. Dates - To/FromII. Title/PositionII. EmployerII. Major ResponsibilitiesIII. Dates - To/FromIII. Title/PositionIII. EmployerIII. Major ResponsibilitiesCommunity/Civic InvolvementPlease list no more than 5 civic/community organizations that you are or have been a part of, including dates.EducationDegrees/CertificationsPersonal PerspectiveWhat 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?The 2018-19 class of Impact Fellows will work on a health-related issue of regional significance, with the specific topic to be determined. What health-related issue do you feel is most pressing for our region?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 2018-19 Impact Fellows program and all program days. I am willing to make the August to May commitment for the 2018-19 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.
