IACP 2021/2022 Leadership Academy Application

INSTRUCTIONS

Please make sure you are logged into your account prior to starting the application. The form will now allow you to save a draft if you are not logged in.
Please frequently click "Save Draft" at the bottom of your screen as you progress through the form so that you can return to your application easily, this also helps to ensure the system collects your data as the server refreshes periodically.
We require three letters of references/recommendations. If you are a member of a practice group, one letter should be from a leader in your practice group. One should be from someone outside your practice group. Please have your recommenders submit directly to IACP Executive Assistant, Rebecca Evans.
All applications with accompanying documentation must be received by May 17, 2021, at 5 pm Pacific time.
No late or incomplete applications will be accepted.

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Contact

First Name *

Last Name *

Street Address *

City *

Country

Postal Code *

Phone Number *

Email *

What is your preferred pronoun? (he, she, they...) *

Professional Background *

Do you certify that your professional licensure is currently in good standing? *

Date and location of Introductory Collaborative Practice Training: *

Practice Group Affiliation *

If you are not in a Practice Group, please tell us why *

Practice Group contact name: *

Practice Group contact phone *

Practice Group contact email *

Positions held, if any, in Practice Group governance *

Other Practice Group Affiliations

Are you an active IACP member? *

Yes