Application Form
Complete this form if you are interested in participating in the KPA Leadership Academy.
Contact Information
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Diversity Matrix
Diversity of Work Setting
Please Select
Independent Practice
Education
Science
Public Interest
State Employee
VA
Hospital/Academic Medical Center
Other (please specify)
Work Setting - Other:
Diversity of Career Stage
Please Select
Graduate Student
Early Career (0-10yrs)
Mid-Career (11-20yrs)
Late-Career (21+ years)
Geographic Diversity
Please Select
Louisville Area
Lexington Area
Eastern KY
Western KY
Other (please specify)
Demographic Diversity
Race/Ethnicity (specify)
Gender Identity
Sexual Orientation
Neurodiverse
Disability
Religion
Nationality
Other (please specify)
Demographic Diversity - Other:
Please include any additional details that you would like to share related to your demographic diversity.
Please include any areas of diversity with which you identify not included above
Leadership and Growth Insights
Please detail your current and previous leadership experience
How do you plan to use the skills you gain in this program to advance psychology (Please speak to leadership goals you may have in your work setting, community, KPA, and/or APA)
You will be working on a Leadership Project during this program, with guidence from your mentor. This project should highlight how you can take on a leadership role in psychology. Please provide a brief proposal for your Leadership Project, if you don't have a concrete idea for your project, please include your interest areas. We will use this information to help match you to a mentor.
You can be creative and think broadly! If you are interested in applying but unsure what this might look like, please reach out to (eric.russ@kpa.org). Questions and dialogue are welcome!
Describe the characteristics and qualities of an ideal mentor
Curriculum Vitae
Please upload a copy of your CV
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