Action Learning Project

SUBMISSION FORM

This form can be completed in Word using the tab key to move to each field. Select check boxes with your mouse or tab and press the space bar. Please limit your responses to 250 words or less. Email your completed form to program@leadershipws.org no later than the due date below. If you have questions email programdir@leadershipws.org or call 336.723.1002 x206.

Due by August 16, 2017

Submission Date/Revision Date
Community Project Partner (organization):
Project Contact
Phone	Fax
Mailing Address
City
State	Zip
Email

Instructions

Complete each response in the space provided. Answers should be brief and well thought out.

Provide a brief overview of your organization. Please include your mission statement. (You may also include brochures of your program or agency.)

Check the general category this project relates to, or check “Other” and specify a new category.

Education	Gov’t, Criminal Justice & Public Safety	Human Welfare	Social Capital
Arts	Health Care	Economic Dev

Other (Please describe)

Describe the community dilemma, issue or opportunity for the action learning team of approximately 6-8 people to address: (Cannot be related to fund raising or have a political or religious agenda)

What do you envision as the outcome of this project? Who would be the direct and indirect beneficiaries of this effort?

What are you asking Leadership Winston-Salem participants to do, understanding their volunteer time commitment is an average of 20-25 hours over the course of approximately 6 months (Nov-May)?

As the Community Project Partner, will you be able to make yourself or other key resources available to the team throughout the project period?

Additional comments:

Are you the staff person at your agency who has primary decision making authority regarding this project and the execution of its resulting deliverables?

Yes	No

As the Community Project Partner, is there anything you would like to share about your background/interest in this topic?

Do you give us permission to use information/ images from your Action Learning Project final presentation on our website or through our social media platforms?