2019 Kentucky Advocacy Network Application
Please note your application must be submitted by December 14th at 3:00 pm or it will not be reviewed
If you have any questions or concerns please feel free to contact Lacey Back at lacey.lane@kedc.or
Email address *
First and Last Name *
Your answer
5 DIGIT KSHA membership identification number *
Your answer
Address *
Your answer
The contact address provided is my: *
Daytime Phone Number ex. (xxx) xxx-xxxx *
Your answer
Evening Phone Number ex. (xxx) xxx-xxxx *
Your answer
Mobile Phone Number ex. (xxx) xxx-xxxx *
Your answer
Years of KSHA Membership *
Your answer
Certification *
Describe your goals as an advocacy leader in your profession and share an example of a professional or volunteer experience in which you either took a leadership role or provided leadership in some capacity. (500 words) *
Your answer
By checking YES in the box below I acknowledge that if I am selected to participate in the Kentucky Advocacy Network (iKAN) I agree to fulfill all program requirements including: the in person workshop at the KSHA Convention on February 20th in Lexington Kentucky, the three online webinars and completing all pre and post workshop activities. I also acknowledge that my participation in all of the required components of the program is critical to the success of the program.
A copy of your responses will be emailed to the address you provided.
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