The Sixth Annual
Leveraging Privilege for Social Change

Required Questions: Basic Info

Complete Name:


Nickname (what you prefer to be called):


Organization Name (if applicable):


Street Address:


City:

State/Province:	Zip/Postal Code:

Country:



Phone Numbers: (please include country code, city (area)code, phone number, and any extensions)

Work Phone Number


Home Phone Number:

Pager Number (if applicable):	Cellphone Number (if applicable):

Fax Number:


Email Address:


Website of Group (if applicable):

Birthday (month/day/year):	Age:

Gender:


Ethnic Background:


Sexual Orientation: (optional - We value diversity of sexual orientation at our programs, and celebrate the opportunity to take a stand to create a safe space for everyone.)


How did you hear about the Jam? (Please list sources by name):



Who You Are

What is your work currently? If you're part of one or more groups, what are their names, mission and accomplishments? What is your role in the group(s)? What projects are you actively working on? Please be as specific as possible, including kinds of strategies used, depth and breadth of focus, staff or volunteer size, how many people are reached, etc.


What inspired you to want to make a positive difference in the world? Tell us some piece of your story!


An important aspect of the Jam is bridge-building (between movements, issues, cultural backgrounds, faiths, sexual orientations, etc.). Why is this relevant to your work and/or important to you personally at this time? How and when is bridge-building challenging for you? In what conditions has it worked well for you?


Why do you want to attend this event? How do you see its philosophy, principles and goals as relevant to the world today, or to your life and work?


Please share with us any concerns, doubts, fears or reservations that you would have about attending the Jam.


Please give us a mini-bio (a paragraph version of your story) written in the third person (for example using "she" instead of "I"). If you are selected to participate in the Jam, we may ask you if we can use this bio on our website and selected materials to allow event funders to be introduced to you and your work. We will not use it publicly in any way without first obtaining your permission. Giving it to us is also giving us permission to share it with other Jam participants. Talk yourself up! Include any organizations you've started or worked with, awards you've won, contributions you've made, etc.


Anything else you'd like to tell us?



Naming Privilege
We recognize that sharing about our privileges (especially for those with monetary privilege) is not something our society encourages. Most of us have been conditioned to keep such things to ourselves. A core focus of the Jam is an exploration of our privileges and the power (or challenges) they provide. The more you can share about how you see and experience privilege in your life, the more we can deepen these conversations at the Jam. Please share as openly as you can. So in that context, and in full confidentiality, we invite you to tell us about your current context in as much detail as you feel comfortable sharing.

What moves you to apply for this event? How do you see yourself as privileged – and what are the specifics of that? Please be as specific as possible.

If monetarily -- what is the scale, and what is your level of access or authorship?; If through position – what is the position, how does that power live for you, and what does it mean?; If, through fame – how many people do you impact and how does fame play out for you?; If through education – what is your educational background, what does it mean to you, what does it give you, and how do you work with that?; etc.


What are a few issues or questions that you struggle with around this privilege (or these privileges)?


How have you been (or how would you like to be) leveraging this privilege(s)?  (giving away money, donating time, being a spokesperson for causes, or... ?)



Costs of Attending

Tuition (including program, lodging and meals) is $2,000. A number of full and partial scholarships are available upon request, on an as-needed basis.. Additional donations above the event price are welcome, and help us to provide scholarships to enable the diversity upon which this event thrives (they are also tax-deductible).

1. TUITION: Are you or your organization in a position to pay the $2,000 tuition? If no, what level of scholarship would you or your organization need in order for you to attend?


2. TRAVEL: If you come to Jam, what airport would you by coming from? You would be flying into Charleston, West Virginia. Are you or your organization in a position to cover the travel costs? An extremely limited number of travel scholarships will be available.


Thanks so much for taking the time to fill out this LONG application! We'll be in touch as soon as we can.