Form Builder

Part 1 - Personal Information

First Name

Middle Name or Initial

Last Name

Street Address

City

State

Zip Code

County

Primary Phone Number

Primary E-Mail Address

Secondary E-Mail Address

Currently employed?

Employer (indicate “self” if self-employed & "N/A" if you are a current student)

Job Title

Part 2 – Demographics

Gender

Enter Gender

Race

Enter Race

Ethnicity

Enter Ethnicity

Religious Affiliation

Enter Religious Affiliation

Date of Birth

Part 3 - Education

Undergraduate Degree

Year

Major

Institution

Post-Graduate Degree

Year

Institution

Awards/ Honors/ Certifications you have received:

Part 4 - Leadership/Community Experience

Please limit responses to 150 words.

Please list any organization(s) with which you are or have been active. Please tell us your role in the organization:

Describe the impact that this involvement has had on you, the organization and beyond.

What skills have you acquired through participation in this (these) organization(s)?

Part 5 – Goals and Interest Areas

Please provide your reasons for participating in ISBLI and how you envision using your ISBLI skills to contribute to community life and civic engagement. Please limit responses to 150 words per response.

List three goals or objectives you hope to accomplish during your ISBLI experience:

List all skills you hope to improve through your ISBLI experience:

What impact do you intend to make on your community following your ISBLI experience?

Do you commit to attend every session outlined in the program calendar, and complete the group project mandatory for the program?

*Note – a “No” answer may negatively impact your application

If you answered "No” please explain your reasons.

Do you have the necessary tools to participate effectively (laptop/tablet/smartphone/internet)?

How did you hear about ISBLI?

Part 6 – References

Please provide the name and contact information of two references who can attest to your character, service, leadership, and community involvement.

First Reference:

Title (e.g., Mr., Ms., etc.)

First Name

Last Name

Name of Organization

Title/Position:

Telephone Number:

E-mail address:

Relationship to you:

Second Reference:

Title (e.g., Mr., Ms., etc.)

First Name

Last Name

Name of Organization

Title/Position:

Telephone Number:

E-mail address:

Relationship to you:

Part 7 – Payment Information

How will you pay the 2023 tuition?

Payment Options

SINGLE PAYMENT (One payment for full amount of tuition)
THREE PAYMENTS (First payment 50% down plus two remaining monthly payments of 25% each)

All payments must be completed by December 20, 2022

Payment Method

PayPal
Credit Card (Please note that all credit card/debit card transactions include a processing fee)
Check

If you are applying for a scholarship, you must indicate a value in the next question.

Annual Household Income (approximate required if requesting financial assistance):

Please upload your resume or bio / biographical statement here (pdf, doc, etc)

Part 8 – Code of Conduct

The ISB Leadership Institute (ISBLI) is an initiative of the Islamic Speakers Bureau of Atlanta in partnership with Kennesaw State University's (KSU) Division of Global Affairs and other industry thought leaders and practitioners. Participation in the ISBLI program is subject to the observance of the organization’s and University's rules and procedures. The activities outlined below are strictly prohibited. Any participant or program team member who violates this Code is subject to discipline, up to and including removal from the program.

Abusive language towards an ISBLI team member, trainer, coach, or another participant.
Possession or use of alcoholic beverages or illegal drugs on Kennesaw State University property and/or other program facilities.
Reporting to the program while under the influence of drugs or alcohol.
Bringing dangerous or unauthorized materials such as explosives, firearms, weapons or other similar items to Kennesaw State University or other program facilities.
Discourtesy or rudeness to a fellow participant, ISBLI team member, coach or trainer.
Verbal, physical or visual harassment of another participant, ISBLI team member, coach or trainer.
Actual or threatened violence toward any individual or group.
Conduct endangering the life, safety, health or well-being of others.
Failure to follow any agency policy or procedure.
Bullying or taking unfair advantage of any participant.
Failing to cooperate with any trainers, coaches, ISBLI team members, group members, or other participants.

I have read and I understand the ISBLI’s Code of Conduct. By writing my virtual signature below, I agree to abide by the rules described above and understand that if accepted into the program, I may be removed as a participant if I violate any of these rules.

Date of Signature

Please make sure you have completed all fields and check for accuracy prior to pushing the SUBMIT button. Thank you.

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