HLD Application

Name*
First Last
Preferred Pronouns*
What would you like us to call you? Example: Elizabeth vs Liz; Margaret vs Maggie*
Credentials (In none, N/A)*
Years of Professional Experience*
Business Information
Present Employer*
Type of Organization*
Position*
How did you hear about us?*
If you selected "Other", please share how you found us.
Business Mailing Address
Street Address Address Line 2 City State ZIP Code
Business Phone*
Business Phone Ext.
Business Email

Home Information
Home Mailing Address
Street Address Address Line 2 City State ZIP Code
Mobile Phone*
Personal Email*
Additional Information
Would you prefer email sent to your business or personal email address?*
- Business
- Alternate
Any Dietary Restrictions? If none, type "none."*
Emergency Contact Name*
First Last
Emergency Contact Relationship*
Emergency Contact Phone*

Personal Profile
Please attach a current resume or curriculum vitae*
Max. file size: 300 MB.
Strengths*
The Program is committed to building share learning and trust among diverse leaders and across multiple interests. Please describe your unique strengths, background, attributes, or dimensions of diversity that you would bring to the class.
Statement of Purpose*
Please briefly describe what you hope to gain for yourself and/or your organization from the HLD course.
Leadership*
We are seeking individuals with a record of accomplishment and leadership within an organization or at the community, statewide, or professional association or society arenas. Please describe how you have, or are currently leading in Maine.
Commitments*
We are seeking candidates who are personally committed to improving the future of health and healthcare in Maine. Please describe how you have expressed this commitment in your work or volunteer life, including how much you demonstrate your passion for your work.

HLD Expectations and Commitments

Please take a few minutes to read what is expected from you as an HLD participant:

All applicants must:
- Confirm that all HLD session dates are on your calendar
- Attend every session, on average, 2 days per month, September- April
- Attend all 3 days of Outward Bound
- Participate fully with an open heart and mind
- Fulfill all learning projects required by the program
- Respond to all session evaluations
- Actively contribute and participate at each session
To be completed by the applicant: I have read the above expectations and commitments of the HLD course, and agree to all requirements described above.

Please sign here:
Name*
First Last
Photography Use*
Do you give consent to have your photograph, video, and likeness used for Hanley publicity purposes?
- Yes
- No
Date*
MM slash DD slash YYYY

References

Please list three references (if you are the CEO of your organization, one of the reference should be from your employer or sponsoring organization):
Reference # 1 Name*
First Last
Reference # 1 Title*
Reference # 1 Organization*
Reference # 1 Phone*
Reference # 1 Email*
Reference #2 Name*
First Last
Reference #2 Title*
Reference #2 Organization*
Reference #2 Phone*
Reference #2 Email*
Reference #3 Name*
First Last
Reference #3 Title*
Reference #3 Organization*
Reference #3 Phone*
Reference #3 Email*

Organizational Commitment (if applicable)

I have spoken to my organization regarding the HLD course. The below individual supports my participation, which includes allowing me time off from assigned duties to attend all sessions of the HLD course.
Name of Supporting Individual
First Last
Title of Supporting Individual
Email of Supporting Individual
Phone of Supporting Individual
A non-refundable application fee of $50 is required from prospective applicants. You will be invoiced for this fee following the submission of this form.

Tuition Information
- Tuition for the Health Leadership Development 2023-2024 16-day leadership course is $6,300, and includes all meals, instructional materials and Outward Bound experience. It does not include travel and the cost of overnight accommodations other than Outward Bound.
- Tuition assistance is available on a limited basis to ensure our ability to involve many dimensions of Maine’s health and healthcare community. If seeking tuition assistance, please request the Tuition Assistance Request Form by emailing Maggie Adelson at maggie@hanleyleadership.org. Tuition Assistance will be awarded based on need and availability of resources. Tuition Assistance requests are confidential.
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