Application for Individual and Group Anti-Racist Leadership Coaching
Allow 10-15 minutes to complete. If you haven't already, please review the details at

Note: Though not required, we encourage you to sign up in pairs or small groups of people that you interact with, or would like to interact with regularly, as it makes the work more fun and more relevant. Copy and paste this link to share with others: 
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Email *
We're delighted to meet you! We're Cleo Manago and Jill Nagle. What is your name? *
Are you applying as an individual, or with others? If with others, please complete the next question. If as an individual, you can skip it. Note: If you are applying as a group, each member should fill out their own application.
This is a three-part question: What is the nature of your group? For example, friends, colleagues on a marketing or health care team, and so on. How many in your group? Who is the main contact person for the group?
How did you hear about the program? If a personal referral, who?
Who else (if anyone) are you applying with? If no one currently, can you think of 1-3 people in your geographical area (or elsewhere) that you would like to do this work with?
Telephone number?
City, state or province, and country?
Which age group are you in?
Clear selection
If there a website or social media link that tells us more about you or your work that you're willing to share, please do so below.
What time zone are you in? *
What are you most passionate about leading or working on in the next 6 months to a year? *
What is your experience leading the thing you are most passionate about? What have been your greatest successes and biggest challenges? *
What do you anticipate will best support your efforts in 2022? (Check all that apply) *
What if any personal or spiritual growth approaches, traditions, training programs or groups have you been part of in the past? Which of these has been most useful and why? Which has been least useful and why? *
What attracts you to Jill and Cleo in particular? *
All levels of experience are welcome. What is your level of experience with dismantling white supremacy? *
Bare-bones beginner
What is your level of commitment to dismantling white supremacy? *
Minimal commitment
Maximum commitment
How do you see dismantling white supremacy as relevant to your leadership goals? *
What is your ethnic background? Check all that apply. (Note: The program is geared specifically toward white-identifying people who generally receive white privilege, even if you have other ethnic heritage)
Anything else you'd like to share about your background, and how it shapes who you are and how you feel in the world? (For example, gender identification, nationality, sexual orientation, physical ability, and so on).
Any fears or concerns?
In general, what are some good times for a 20-25 minute interview? All times below are Pacific time. *
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