Blandin Foundation Leadership Programs does not and shall not discriminate on the basis of race, color, religion (creed), gender, gender expression, age, national origin (ancestry), disability, marital status, sexual orientation, or military status, in any of its activities or operations. These activities include, but are not limited to, selection of volunteers including program participants and vendors, and provision of services. We are committed to providing an inclusive and welcoming environment for all members of our staff, participants, volunteers, independent contractors, and vendors.

We respect that your personal information is sensitive and we are mindful about how we share it and who we share it with. Your name and contact information will be shared with alumni, partners, selection committee, and your cohort to connect leaders in rural Minnesota to help build healthier communities.

Tell Us About You

Leaders Partnering to End Poverty (LPEP) Application Form

First Name

Preferred First Name

The first name you would like to appear on your name tags

Last Name

Home Mailing Address

Home City

Home State

2 character limit

Home Zip/Postal Code

Personal Email

Work Email

Preferred Email

Home Phone

Work Phone

Mobile Phone

Preferred Phone

What is your occupation?

Why would you like to participate in the LPEP program?

Demographic Information

Please take the time to answer the following demographic questions. We use this information to help us ensure that that all voices in the community are being heard and that our programs are reaching across the 9 dimensions.

Age

Gender Identity

Sexual Orientation

Gender - Self Description

Please provide us with your description of your gender.

Additional Race / Ethnicity Information

Are you currently experiencing poverty?

Have you ever experienced poverty?

Do you identify as someone with a disability or impairment?

Questions? Contact Tom Sippola at tjsippola@blandinfoundation.org or at 877-882-2257 Ex 737.

The Blandin Foundation reserves the right to rescind any invitation to participate in any of its programs up to, and during, the program.

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