Contact Information
Name: 
UR ID#:
Campus Address:
Campus Phone:    Cell Phone:
Home Address:
City, State, & Zip Code:
Email: 
T-shirt size: 

Please list UR initiatives & organizations you are involved with.  List any leadership positions you hold or have held and how long you have been involved in each program.
 

List three things you hope to contribute and 3 things you hope to gain from your involvement in The Allies Institute.


After the Allies Institute, how will you actively support the participants both personally and as change agents at UR?


FOR FACULTY/STAFF APPLICANTS ONLY: Faculty, staff, and students interact at the Institute on an equal playing field.  How will you maintain your role as a faculty or staff member while continuing to offer support to the Allies Institute students once you return to campus?


FOR STUDENT APPLICANTS ONLY: It is sometimes challenging for students to be comfortable as role models for their peers.  Addressing this challenge can begin by accepting the idea that the purpose of going back to the Allies Institute is not to attempt to replicate the participant experience, but to facilitate the best possible experience for others.  How will you balance the demands of being both a peer and a student staff member?

Demographic Information
This information will be used to ensure a diverse representation of backgrounds among the Allies Institute Staff.

Please choose one of the following
Faculty
Staff
Student:  Attended the Institute in- 20052006 2007 2008 2009
National Origin:  Race:    
Religion or Belief System (if any): 
Gender:   malefemale
Do you consider yourself part of the LGBT community? yes no

Agreement
I understand that all selected staff members are expected to complete and turn in paperwork, attend a lunch overview meeting to be tentatively held on Friday, November 20 at 12:30pm.

  I agree: yes no