LeadAbility Regional Course October 25, 2018/in Archive /by Alex Dook Step 1 of 4 25% Welcome! We are delighted you are interested in applying for Leadership WA’s Regional LeadAbility Courses in 2019. The LeadAbility Course is supported by the Department of Communities - Disability Services. This application form is for our regional course in the Peel Region from August to November. Please note this location is subject to a sufficient number of applications. Please note the following: • All applications are confidential. • Applications will be assessed by the selection panel and short-listed applicants will be contacted for an interview. • All applicants will be advised of the outcome of their application once the selection process has been completed. When Ready to Submit Our preference is to receive online applications. To submit an online application, click the Next button. If you prefer, a Word or PDF document can be either downloaded, emailed out or posted to you. Click here to download PDF version Click here to download Word version To request a printed version, call +61 (08) 6381 6700 or email LeadAbility@leadershipwa.org.au and the form will be posted to you. This printed form can either be scanned and emailed back to us at the above email address, or posted to GPO Box 2500, St Georges Terrace Perth 6831. Personal DetailsName* First Last Email* Phone*Preferred contact type*EmailPhoneplease upload a headshot.I would like to apply for the Regional LeadAbility course in:*Peel RegionKarrathaDate of Birth* Country of birth* AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Gender:*FemaleMaleI am of Aboriginal or Torres Strait Islander origin:*YesNoI have a disability:*YesNoI am the family member/carer/advocate of a person with disability:*YesNoHighest Qualification Achieved*Doctoral degreeMasters degreePost Graduate Certificate/DiplomaBachelor DegreeAssociate DegreeAdvanced DiplomaDiplomaCertificateHigh School GraduateDid not GraduateInstitution Name*Completed (Year)*Please enter a number less than or equal to 2100.Other awards, honours, and prizes achieved:* Current Employment DetailsI am currently:*Employed by an organisationSelf-employedUnemployedWorking in a volunteer capacityWorking in a carer capacityMy employer is in the disability sector:YesNoOrganisation NameEmployers Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Employers PhoneCurrent PositionSince (Year)Please enter a number less than or equal to 2100.Please provide a brief overview of your current role (if applicable):* Community EngagementMy main community interests are:*Personal StatementWhy should you be selected for LeadAbility?*Referee 1 name* First Last Referee 1 Position Title*Referee 1 Organisation*Referee 1 Direct Phone*Referee 1 Email* Referee 2 Name First Last Referee 2 Position TitleReferee 2 OrganisationReferee 2 direct phoneReferee 2 Email How did you hear about the LeadAbility program*My employerSpeaking to a Fellow or Alumni of Leadership WAReviewing Leadership WA websiteCorrespondence from Leadership WACorrespondence from Department of CommunitiesReferral by a friend or colleagueInternet search resultLinkedIn or other Social MediaDeclarationPlease consider the Course Dates when applying, as your attendance is expected at all experiences.I understand the goals and commitment I am making to Leadership WA's LeadAbility Course and if selected, I will:* • Devote the required time to participate fully at each experience. • Actively participate in all aspects of the Course including the community project. I require an Auslan interpreter for my interview.*YesNo http://www.leadershipwa.org.au/wp-content/uploads/2016/09/LSWA_master-logo-300x84.png 0 0 Alex Dook http://www.leadershipwa.org.au/wp-content/uploads/2016/09/LSWA_master-logo-300x84.png Alex Dook2018-10-25 09:47:432019-04-10 15:36:52LeadAbility Regional Course
