Please Utilize Microsoft Word to Complete This Form

Please utilize Microsoft Word to complete this form.

Applicant Name:

Relationship to applicant:

___Personal

___Professional

How long have you known this individual? ___

Applicant readiness for leadership development

To what extent do you agree or disagree with the following statements as they pertain to the individual applying for the Leadership Forum/ADLP with 5 being strongly agree and 1 being strongly disagree:

5 4 3 2 1 Attending the Forum/ADLP this year makes sense for this applicant

The applicant has shown a commitment to developing and growing as a leader

The applicant is open to self-reflection and willing to make improvements

There is potential for this person to occupy future leadership positions for which attending the Forum/ADLP will prepare them

Based on the applicant’s trajectory, the applicant will put what they learn at the Forum/ADLP into action following their participation

Open ended questions:

What are this candidate’s two or three main leadership strengths?

 Please discuss a specific example of how this candidate has demonstrated leadership to date If this candidate is selected to participate in the ADLP/Leadership Forum what two or three areas could be strengthened by their participation in this program?

Where do you see this applicant utilizing the skills taught in the ADLP/Leadership Forum programs?

Academic Dermatology Leadership Program (ADLP) Applicants only Do you feel that this applicant has the time to dedicate to the ADLP and the development of a mentoring relationship, including attending the required sessions at the Annual and Summer Meetings and the Leadership Forum?

Please share any additional information you feel the committee needs to know about this applicant.

Overall ranking:

Please rank the applicant on a scale of 1-10 with 10 being Self-aware and willing to grow and 1 being Inflexible and lacks insight.

1 2 3 4 5 6 7 8 9 10 Inflexible and lacks insight Self-aware and willing to grow ______Signature Date

______(Name – please print or type)

Please return to Jaime Lewen via fax (847-240-8719) or email as a PDF attachment to [email protected] by September 15, 2017.