Contact Information

Contact Information

Community Outreach and Engagement Division

Title

Bloomington Leadership Program Application

Sections

Submit this form to apply for the 2021 Bloomington Leadership Program

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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Bloomington Leadership Program Application
Contact info
Questions
Are you able to commit to attend 75% 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.
Race/ethnicity
Preferred gender pronouns
Age
Signature

I agree that by entering my name into the box below and then clicking the "Submit" button on this form, I am providing an electronic signature with the legal standing of a handwritten signature. My signature serves to attest that the responses I have supplied via this form are truthful, accurate and complete.

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

Please take notice that any data received by the City as the result of submitting this form will be classified as government data pursuant to the Minnesota Government Data Practices Act, Minnesota Statutes Chapter 13. Under the Data Practices Act, some or all of this data is classified as public data, including your name, address, email address, phone number, and other personal information provided by you. Public data is available to anyone requesting it and consists of all data furnished via this Web form. Please be advised that the correspondence will be added to the public record. The purpose and intended use of the information collected through this form is to obtain public input and data in support of City activities and services. You have the right to refuse to submit this form. If you choose not to submit this form, you will need to contact the City by another means if you wish to provide the information collected by the form.

The City of Bloomington does not discriminate against or deny the benefits of its services, programs, or activities to a qualified person because of a disability. To make a request for a reasonable accommodation, ask for more information, or to file a complaint, contact the Community Outreach and Engagement Division, City of Bloomington, 1800 West Old Shakopee Road, Bloomington, MN 55431- 3027; 952-563-8733, MN Relay 711.