Class of 2022 MCLP Participant Applicant Reference Form

MCLP Participant Applicant Information

MCLP Participant Applicant Name

If the applicant's name is not already pre-populated below, please enter it.

First Name *

Last Name *

MCLP Participant Applicant Reference Information

Name of person completing reference

Please enter your name and the information requested.

First Name *

Middle Name

Last Name *

Pronouns

Gender

Preferred Phone Number *

Phone Type *

Phone Location *

2nd Phone Number

Phone Type

Phone Location

Preferred Email *

Email Location *

2nd Email

Email Location

Relationship to Participant Applicant *

Leadership Assessment

Please check the column that most accurately reflects your assessment of the nominee.

Superior = outstanding excellence of this nominee. Excellent = a strong rating. Good, Fair, and Not Applicable (NA) are self-explanatory.

Leadership Assessment Grid *

	Superior	Excellent	Good	Fair	Not Applicable or Not Observed
Esteem in which they are held professionally *	Esteem in which they are held professionally - Superior	Esteem in which they are held professionally - Excellent	Esteem in which they are held professionally - Good	Esteem in which they are held professionally - Fair	Esteem in which they are held professionally - Not Applicable or Not Observed
Demonstrated leadership *	Demonstrated leadership - Superior	Demonstrated leadership - Excellent	Demonstrated leadership - Good	Demonstrated leadership - Fair	Demonstrated leadership - Not Applicable or Not Observed
Currently handles leadership responsibility *	Currently handles leadership responsibility - Superior	Currently handles leadership responsibility - Excellent	Currently handles leadership responsibility - Good	Currently handles leadership responsibility - Fair	Currently handles leadership responsibility - Not Applicable or Not Observed
Ability to work with others *	Ability to work with others - Superior	Ability to work with others - Excellent	Ability to work with others - Good	Ability to work with others - Fair	Ability to work with others - Not Applicable or Not Observed
Communication skills *	Communication skills - Superior	Communication skills - Excellent	Communication skills - Good	Communication skills - Fair	Communication skills - Not Applicable or Not Observed
Passion for becoming a better leader *	Passion for becoming a better leader - Superior	Passion for becoming a better leader - Excellent	Passion for becoming a better leader - Good	Passion for becoming a better leader - Fair	Passion for becoming a better leader - Not Applicable or Not Observed
Overall leadership potential *	Overall leadership potential - Superior	Overall leadership potential - Excellent	Overall leadership potential - Good	Overall leadership potential - Fair	Overall leadership potential - Not Applicable or Not Observed

Please explain why you believe this nominee and our community will benefit through their participation in MCLP.

Please explain why you believe this nominee and our community will benefit through their participation in MCLP *

Do you have any additional observations about this individual that you would like to share?

Additional Observations Value *

Certification

For a participant to develop fully as a leader with the Multicultural Leadership Program takes a team effort. You, as reference for an applicant to the next MCLP class, have completed this form to the best of your ability. If the applicant is accepted into the program, you will become part of this individual’s circle of support. Although only the participant is allowed to attend MCLP learning events, the information can be shared with you by the participant. I understand this and pledge my cooperation and support.

Signature *

Type your name

Date *

Month

Day

Year

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Class of 2022 MCLP Participant Applicant Reference Form