OFFICE FOR INCLUSION, DIVERSITYAND EQUAL OPPORTUNITY
Train the Champion Program
Class of 2016
APPLICATION FORM
Deadline Date: December 28, 2015
Please return the application to janetta.hammock@case.edu
Please attach your most recent curriculum vitae or resume
Full Name: ____________________________________________________________________
Preferred Name:
________________________________________________________________
Position/Title: __________________________________________________________________
School/Department: _____________________________________________________________
Number of Years at Case Western Reserve:
__________________________________________
Mail Location: _________________________________________________________________
Phone Number: ________________________________________________________________
E-mail Address________________________________________________________________
Direct Supervisor: ______________________________________________________________
Discuss your interest in Train the Champion and what you hope to gain from the program.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
List any campus/community involvements, or roles in leadership, including previous or
current:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Supervisor Information:
My direct supervisor is aware of the Office for Inclusion, Diversity and Equal
Opportunity’s Train and Champion Program and supports my full participation in the
program.
Direct Supervisor’s Signature
________________________________________________
Date
__________________
Dates of Participation
In order to successfully complete the Train the Champion Program, participates are
permitted to miss only two sessions. Unless otherwise noted, all sessions are held
11:30 a.m. to 1:00 p.m. (excluding the first and last sessions). Tentatively, the sessions
will be held on the third Tuesdays of each month beginning in January through
November with the January meeting being held all day and the last session in
November lasting for two hours. Tentative dates for 2016 are as follows:
January 19, 2016 (all day) - MANDATORY ATTENDANCE
February 16, 2016
March 15, 2016
April 19, 2016
May 17, 2016
June 21, 2015
August 16, 2016
September 20, 2016
October 18, 2016
November 15, 2016 (2 hour session)
Participant’s Signature: ________________________________ Date:
___________________
In an effort to create an inclusive and diverse group of participants for the Train the
Champion Program, the Office for Inclusion, Diversity and Equal Opportunity requests
that applicants complete the OPTIONAL demographic information below. Do not
provide this page to your supervisor when requesting your supervisor’s
signature on the prior page.
The Office for Inclusion, Diversity and Equal Opportunity will use the following
data solely for purposes related to the Train the Champion Program. The
following questions are OPTIONAL. If applicants choose not to disclose the
following information, they will still receive equal treatment and consideration for
the Train the Champion Program.
How would you self-identify in the following categories:
Race:
Ethnicity:
Religion:
Gender:
Nationality:
What is your date of birth?
Do you have a disability? ( ) Yes ( ) No
Case Western Reserve University does not discriminate in recruitment, employment, or
policy administration on the basis of race, religion, age, sex, color, disability, sexual
orientation, national or ethnic origin, political affiliation, or status as disabled veteran or
veteran of the Vietnam era.