Contact Information

Contact Information

Community Outreach and Engagement Division


Bloomington Leadership Program Application


Submit this form to apply for the Bloomington Leadership Program or download a PDF application and return it to

Your submission will be delivered to the  City of Bloomington's Community Outreach and Engagement Division. 

Space is limited. A selection committee will review and select participants. Be sure to provide enough information for the selection committee to learn about you (for example, one paragraph).

The program is offered in English. If you’d like to request a language accommodation, please contact the Community Outreach and Engagement Division

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Contact info
How did you learn about the Bloomington Leadership Program?
Select all that apply
Are you able to commit to attend 80% of the program meetings (no more than 2 absences)?
Demographic information (optional)

This section is voluntary. Any information you provide us is private data. The information is used to help our staff use the most respectful language when addressing you, and to monitor our success at attracting a diverse cohort of residents for the Bloomington Leadership Program. Having leaders who reflect the community we serve builds connections, enhances trust and expands perspectives, which ultimately results in better service to all residents.
Preferred gender pronouns

I understand that if selected for the Bloomington Leadership Program and alumni network, participation in the activity(ies) or program(s) is completely voluntary and that the activity(ies) or program(s) being offered is for the benefit of the participant(s). The City of Bloomington shall not be liable for any claims, injuries, or damages, of whatever nature, incurred by the participant(s) which are directly or indirectly attributable to the negligence, whether passive or active, of the City of Bloomington, their agents, or employees, arising out of, or in connection with the activity(ies) or programs. On behalf of the participant(s) and myself, I understand that I am waiving certain legal rights by agreeing to this Waiver and expressly agree to release and discharge the City of Bloomington, their agents, or employees, from any such claims, injuries, or damages. I also understand this waiver includes any injuries that may result from the condition of facility used in the activity or program.  

I understand that City staff may take video or photos of City sponsored activities. By signing this application, I waive any objection to the City sharing my name and/or my image in its promotional materials. If I wish to object the use of my image, then I will make my request known to the City of Bloomington in writing.