Test Form CONTACT INFORMATION: First Name * Last Name * Organization Name * Position/Title * Preferred Address: Street * City * State * Zip * Business Phone * XXX-XXX-XXXX Home Phone XXX-XXX-XXXX Mobile Phone XXX-XXX-XXXX Preferred E-mail Address * Alternate E-mail Address How did you hear about BRI? Please help us credit the correct source by listing it below. BRI Leader's Name Website Blog Social Media - Please list site Advertisement - Please list publication Other Source - Please list source PROFESSIONAL BACKGROUND: Are you currently employed in the community services field? Yes No Please answer the following based on your current employment. If you are currently unemployed or retired, please answer based on your last full-time employment, and provide the dates of such employment. What is the scope of your organization? Please select which applies: Local Regional National International What is the nature of the community services, programs or activities your organization provides? Briefly describe your job responsibilities, including the supervisory or management role that you occupy: Please list any special skills, talents or training that you have: Briefly describe any other characteristics or experiences that you believe the Review Committee should know about you when considering participation in the conference. SHORT ESSAYS: Directions: Please answer the following questions. Please attempt to limit your responses to 250 words or less per essay. A. Give one example of a professional achievement. Please describe the achievement, your role in the effort, leadership qualities you demonstrated, how the effort affected others and any personal reflections you would like to share. B. BRI is held in a beautiful and very rural setting and includes accommodations similar to a dorm-type setting (private rooms/bathrooms in older concrete block buildings inside a remote state park; there are some fully equipped cabins available as well). The conference has been likened to “summer camp for grown-ups.” Why does the leadership development and personal renewal this conference offers, in this setting, appeal to you? C. Much of the learning and growth experienced at BRI is informal in nature and gleaned from conversations and relationships with the attendees. What qualities will you bring to the BRI family to further this type of learning? D. In your opinion, what are the most significant problems facing our communities today? How do you or will you attempt to address these problems as a leader in your community? E. In thinking about how you heard about BRI (a current member, saw an ad, found our website), what piqued your interest the most? Why do you feel BRI would be of value to you, professionally or personally? We are excited to hear from you! Is there a message you would like to add? Thank You for considering the Blue Ridge Institute!