CEO & ExecutiveRoundtable Application * 1. Please provide your contact information Name * First Name Last Name Organization * Position Title * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone * (###) ### #### 2. Which of the following best describes your organization? * Health/Wellness Education/Research Environmental/Animals Arts/Culture/Humanities Human/Social/Services International Religious Civic Engagement/Social Justice Trade Other 3. Which of the following categories apply to you? * An association CEO/ED Nonprofit CEO/ED Association Executive (please specify in "other" box below) Public Sector CEO/ED Other 4. If your organization is an Association, how many member organizations do you have? 5. If you are an Association, what is your geographical reach? Local Statewide National International 6. In what range does your organizational budget fall? * Under $500k $500k - $4 million $4,000,001 - $10 million $10,000,001 - $20 million Above $20 million 7. What is the mission of your organization? * 8. Do you report directly to a board of directors? * Yes No 9. If you don't report directly to a board, please describe your relations to the board. 10. About how many employees work at your organization? * 11. How many employees directly report to you? * 12. How do you self-identity? * American Indian or Alaskan Native Asian American Black/African American Hispanic/Latino Native Hawaiian or other Pacific Islander White/Caucasian Multi-ethnic/Multi-racial Would rather not say Other (please specify) 13. How many years have you been in your position? * 14. When you think of your current organizational context, what 3 issues would you most likely get help with? * 15. What about your work most feeds your energy? * 16. On a scale of 1-10 (10 being the best), how would you rate your work/life balance? * 17. When you think of yourself as a whole organizational and community leader, what 3 areas would you most like to develop in yourself? * 18. If you were at the top of your game as a leader, what would that look and feel like? * 19. Why are you interested in participating in a Roundtable? What do you hope to get out of it? * 20. Roundtable meetings will rotate between member organizations. Are you willing to host, which means provide a location and snacks/refreshments, at least once during the year? * Yes No 21. Are you willing to commit to participating in the Roundtable for a year (10 half-day meeting s * Yes No 22. Would you be interested in finding out more about any of the following? Executive Coaching (gives an opportunity to work deeper in a one-on-one relationship) A half or full-day strategizing session (an opportunity to delve quickly into an issue with a coach) On-demand coaching (you get one-on-one coaching only when you need it) Six-month leadership development group coaching program (build you leadership skills with the support of a facilitator/coach and a small group of other leaders) 23. What else, if anything, would you like for me to take into consideration? Thank you!
