Leadership Formation Academy | North Carolina Psychological Association

Name

Preferred Mailing Address

Preferred Email Address

Preferred Phone Number

How long have you been a member of NCPA?

Please list your involvement with NCPA, APA, and/or other psychology-related associations:

What interests you in participating in the Leadership Formation Academy?

Rank up to three areas (in order of greatest preference) in which you would like to expand your leadership capacity:

Describe your vision of leadership in the area(s) identified above

How might you contribute to the diversity of our organization?

I hereby agree to make every effort to attend the initial retreat and subsequent quarterly meetings; to endeavor to complete the work assigned; to engage myself and my colleagues with mindful respect and compassion; and to contribute a portion of my expanded leadership capacity back into NCPA.

Signature

Date

*Please remember to include your CV with your application. Thank you!