Diversity in Leadership Application
Instructions: In order for your application to be considered, the CDA must receive a completed application form and two completed reference forms by February 28, 2019. Applications will be acknowledged when all three documents have been received. All applicants will be notified of their acceptance status by March 15, 2019.

 Time Commitment:
  • 3 face-to-face all-day leadership training courses:
    • April 26, 2019
    • Sept. 20, 2019
    • April 17, 2020
  • Networking dinners in Denver prior to the training courses. Dinners will be held from 6-8 p.m.:
    • April 25, 2019
    • Sept. 19, 2019
    • April 16, 2020
  • Mini Leadership Workshops, available in person or via video conference, from 6:00-7:30 p.m. on:
    • June 19, 2019
    • Aug. 21, 2019
    • Nov. 6, 2019
    • Feb. 5, 2020
  • Active participation in the online platform
  • Completion of a leadership project
  • Mentorship of a Diversity in Leadership future class
 
1.
Contact Information

Please provide your preferred contact information below. This will be used for all program correspondence.

First Name:
Middle Name:
Last Name:
Home Phone:
Email Address:
emailaddress@xyz.com
Address 1:
Address 2:
City:
State/Province
(US/Canada):
Postal Code:

2.
Demographic Information

Gender
Male
Female
Other  
3.
Race/Ethnicity
African-American
Hispanic
Asian
American Indian or Alaska Native
Native Hawaiian or Pacific Islander
White
Other  
4.

Date of Birth

 

50 characters left.
5.

Education and License (Participation is open to all active, licensed dentists, residing in Colorado regardless of their CDA membership status.)


Predoctoral Dental Education

D.M.D
D.D.S.
Other  
6.

Please list:

-Dental School

-Graduation Date

-Advanced Dental Education (Type of Program, Graduation Date)

-Other Type of Program (If Applicable)

 

1000 characters left.
7.

Type of Practice (Select all that apply.)

General Practice
Endodontics
Oral Pathology
Dental Industry
Periodontics
Pediatric Dentistry
Oral Radiology
Dental Education
Prosthodontics
Orthodontics
Oral Surgery
Dental Public Health
Other  
8.
Employment History

Please list your employment experience, with most recent experience first. Include place of employment, position held, date started and date ended. Dates should be entered in mm/dd/yyyy format.
 

1000 characters left.
9.
Memberships, Leadership and Volunteer Positions

Please list current or past memberships in professional and civic organizations, including any leadership/volunteer positions, recognitions and dates. Dates should be entered in mm/dd/yyyy format.
 

1000 characters left.
10.

Essays

Please answer the five essay questions that follow in the spaces provided.


Please describe your interest in the CDA's program, including why you should be selected by the DIL Selection Committee to participate.

 

1000 characters left.
11.

Identify your current leadership skills and list the top 3 leadership development goals you would like to focus on if you were selected for this program. 

 

1000 characters left.
12.

Do you have previous leadership experience in and/or outside of the workplace and if so please explain?

 

1000 characters left.
13.

Following your participation in this program, how might you impact changes in the profession or oral health?

 

1000 characters left.
14.

Please discuss an issue of social or political concern that impacts the dental profession or your community. Why is this issue important and what could be done to resolve the issue at the local, state or national levels? Would you consider pursuing a leadership project in this area through the Diversity in Leadership program?

 

1000 characters left.
15.

References 

Please list the name, phone number and email address of two individuals who will provide a reference in support of your application.

 

350 characters left.
16.
Please describe under what circumstances you know your references and how long you have known them.
 

1000 characters left.
17.

Applicant Agreement 

I hereby apply as a candidate in the CDA Diversity in Leadership program. If chosen to participate, I agree to commit the time necessary for successful completion of the program, including attendance at all three sessions of the program, mini workshops, active participation in the online platform and mentoring future class participants. I acknowledge that all of the information contained herein is accurate and true to the best of my knowledge. If selected, as part of my participation in the program, I hereby grant to the CDA, their agents, partners, sponsors and designees, all rights and permission to use and reproduce my name, likeness (including my photograph), biographic information (including professional credentials) and any statements I make in connection with the program, in any media now existing or hereafter created, for research, education, promotional and marketing purposes. I hereby release and discharge for myself and my heirs, executors, administrators and assigns the CDA, their officers, directors, employees and agents, from any and all claims and demands arising out of or in connection with the exercise of this grant.


Electronically sign and date below, indicating you have read the statements above and agree.

 

350 characters left.
Thank you for your interest in the CDA's Diversity in Leadership program. In order for your application to be considered, the CDA must receive your completed application form by February 28, 2019. Applications will be acknowledged when the completed application form has been received. All applicants will be notified of their acceptance status by March 15, 2019.