Email
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First Name
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Last Name
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VCU Box Number
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Home Street Address(include city, state, zip code)
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Preferred Phone Number
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Alternate Email (for alumni communications)
Organization
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VCU VCUHS Other
If other, please specify
* must provide value
Select the major area you work in within the University, and the major unit.Please note the major area of academic schools and departments fall under the Office of the Provost. If you work in the College of Humanities and Sciences, you will be redirected to a menu to select your specific department. (Refer to this org chart )
Ex: Rodney Ram, Executive Assistant, Department of PsychologyMajor Area: Office of the Provost Unit: College of Humanities & Sciences Professional Title: Executive Assistant
Which major area in the university do you work in?
* must provide value
Office of the President Office of the Provost Office of the Vice President for Health Sciences Office of the Vice President for Finance Office of Institutional Equity, Effectiveness, and Success Office of Development and Alumni Relations Office of the Vice President for Research & Innovation Division of University Relations Division of Administration Division of Strategic Enrollment & Student Success Division of Athletics
Which major unit do you work in?
* must provide value
Audit & Compliance Services University Counsel Office of Government Relations Office of the President
Which major unit do you work in?
* must provide value
College of Humanities and Sciences L. Douglas Wilder School of Government and Public Affairs Richard T. Robertson School of Media and Culture School of World Studies School of the Arts School of Business School of Education College of Engineering School of Social Work VCU Graduate School VCU Honors College VCU Life Sciences VCU Libraries VCU Ombudsperson VCU University College Division of Community Engagement Division of Strategic Enrollment Management Division of Student Affairs Global Education Office Institute for Contemporary Art Online@VCU Student Success Unit Office of the Provost
Which major unit do you work in?
* must provide value
College of Health Professions School of Dentistry School of Medicine School of Nursing School of Pharmacy Massey Cancer Center Office of the Vice President
Which major unit do you work in?
* must provide value
VCU Finance & Budget VCU Treasurer Government Relations Board Liaison Equity and Access Services Office of the Vice President
Which major unit do you work in?
* must provide value
VCU Police and Public Safety Facilities Management Human Resources Technology Services Environmental Health and Safety Real Estate Services Office of the Vice President
What department or center in the College of H&S do you work in?
* must provide value
Dean's Office Department of African American Studies Department of Biology Department of Chemistry Department of English Department of Forensic Science Department of Gender, Sexuality and Women's Studies Department of History Department of Kinesiology and Health Sciences Department of Mathematics and Applied Mathematics Department of Military Science and Leadership Department of Philosophy Department of Physics Department of Political Science Department of Psychology Department of Sociology Department of Statistical Sciences and Operations Research Economics (in H&S) Center for Culture Experiences in Prevention Center for the Study of Tobacco Products Clark-Hill Institute for Positive Youth Development College Behavioral and Emotional Health Institute Humanities Research Center da Vinci Center for Innovation
Professional Title
* must provide value
Your position is best characterized as:
* must provide value
Classified Staff
University & Academic Professional - Executive/Senior Administrator
University & Academic Professional - Academic Professional
University & Academic Professional - Affiliate/Adjunct Faculty
University & Academic Professional
Academic Administrator (with T&R faculty appointment)
Teaching & Research Faculty
Post-Doctoral
VCUHS Clinical Faculty
VCUHS Staff
VCUHS Director/Administrator
VCUHS Executive/Senior Administrator
You are:
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Tenured Faculty Tenure-eligible Faculty Not eligible for tenure Unknown
Approximately how many people do you directly supervise?
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0 1 - 5 6 - 10 11 -15 16 - 20 21 - 25 More than 25
How long have you been employed by VCU or VCUHS?
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5 years or less
6 - 9 years
10 - 14 years
15 - 19 years
20 or more years
I am not employed by VCU or VCUHS
What range best describes your age?
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20 - 29 years old
30 - 39 years old
40 - 49 years old
50 - 59 years old
60 - 69 years old
70 or older
I prefer not to say
Which category(ies) describe(s) your race/ethnicity best? (Choose as many as apply)
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If other, please specify:
* must provide value
What word(s) do you use to describe your gender
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What is the highest educational degree/certificate you have obtained?
* must provide value
High School Diploma or equivalent Associates Degree (or two years post secondary) Bachelor Degree Post-Baccalaureate Certificate Masters Degree (or other professional equivalent) Doctorate Other I prefer not to say
If other, please specify:
* must provide value
In a word or simple phrase, the one thing that I most need from a mentor:
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Many things motivate me, but my top three are:
* must provide value
If you serve as my mentor, you can realistically expect me to:
* must provide value
The following professional goals are important to me:
* must provide value
I have the following professional strengths to help me achieve my goals:
* must provide value
I could use improvement in the following areas to help me achieve my goals:
* must provide value
Coaches (and teammates) can support my work performance and progress toward my goals in the following ways:
* must provide value
Current Position Description (Limit: 200 words or less) Describe your responsibilities in your current position. Focus on the activities, operations, or functions for which you are directly responsible.Â
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Personal Statement (Limit: 700 words or less)
Responses to the following personal statement questions are used to help us learn more about you and as a part of the mentor matching process. Please provide a short essay responding to the following prompts (Limit - 250 words per question). We recommend copy/pasting the questions from a word document for your convenience.
Â
1. Why are you applying for this development opportunity? What professional goals do you have for your leadership development during your participation in the program?
* must provide value
 2. What path would you like your career to take? How do you see your experience with the program fitting in to your long-term career goals?
* must provide value
3. Describe a professional situation in which you took a leadership role. In what ways were you effective? In what ways were you not effective? What did you learn from this experience?
* must provide value
4. How does your leadership role fit in to the larger context of VCU? In what ways can you envision yourself expanding your professional contribution to VCU?
* must provide value
Upload CV/Resume
Upload file as word (doc/docx) or pdf with the file name: Last Name_VCUL2022_CV
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Reference #1
First Name  Last Name Title Email This reference is: Organization    Â
If other, please specify:
Major Area
* must provide value
Office of the President Office of the Provost Office of the Vice President for Health Sciences Office of the Vice President for Finance Office of Institutional Equity, Effectiveness, and Success Office of Development and Alumni Relations Office of the Vice President for Research & Innovation Division of University Relations Division of Administration Division of Strategic Enrollment & Student Success Division of Athletics
Audit & Compliance Services University Counsel Office of Government Relations Office of the President
College of Humanities and Sciences L. Douglas Wilder School of Government and Public Affairs Richard T. Robertson School of Media and Culture School of World Studies School of the Arts School of Business School of Education College of Engineering School of Social Work VCU Graduate School VCU Honors College VCU Life Sciences VCU Libraries VCU Ombudsperson VCU University College Division of Community Engagement Division of Strategic Enrollment Management Division of Student Affairs Global Education Office Institute for Contemporary Art Online@VCU Student Success Unit Office of the Provost
College of Health Professions School of Dentistry School of Medicine School of Nursing School of Pharmacy Massey Cancer Center Office of the Vice President
VCU Finance & Budget VCU Treasurer Government Relations Board Liaison Equity and Access Services Office of the Vice President
VCU Police and Public Safety Facilities Management Human Resources Technology Services Environmental Health and Safety Real Estate Services Office of the Vice President
Department/Center in College of H&S
* must provide value
Dean's Office Department of African American Studies Department of Biology Department of Chemistry Department of English Department of Forensic Science Department of Gender, Sexuality and Women's Studies Department of History Department of Kinesiology and Health Sciences Department of Mathematics and Applied Mathematics Department of Military Science and Leadership Department of Philosophy Department of Physics Department of Political Science Department of Psychology Department of Sociology Department of Statistical Sciences and Operations Research Economics (in H&S) Center for Culture Experiences in Prevention Center for the Study of Tobacco Products Clark-Hill Institute for Positive Youth Development College Behavioral and Emotional Health Institute Humanities Research Center da Vinci Center for Innovation
Reference #2
First Name  Last Name Title Email This reference is: Organization    Â
If other, please specify:
Major Area
* must provide value
Office of the President Office of the Provost Office of the Vice President for Health Sciences Office of the Vice President for Finance Office of Institutional Equity, Effectiveness, and Success Office of Development and Alumni Relations Office of the Vice President for Research & Innovation Division of University Relations Division of Administration Division of Strategic Enrollment & Student Success Division of Athletics
VCU Police and Public Safety Facilities Management Human Resources Technology Services Environmental Health and Safety Real Estate Services Office of the Vice President
VCU Finance & Budget VCU Treasurer Government Relations Board Liaison Equity and Access Services Office of the Vice President
College of Health Professions School of Dentistry School of Medicine School of Nursing School of Pharmacy Massey Cancer Center Office of the Vice President
Audit & Compliance Services University Counsel Office of Government Relations Office of the President
College of Humanities and Sciences L. Douglas Wilder School of Government and Public Affairs Richard T. Robertson School of Media and Culture School of World Studies School of the Arts School of Business School of Education College of Engineering School of Social Work VCU Graduate School VCU Honors College VCU Life Sciences VCU Libraries VCU Ombudsperson VCU University College Division of Community Engagement Division of Strategic Enrollment Management Division of Student Affairs Global Education Office Institute for Contemporary Art Online@VCU Student Success Unit Office of the Provost
Department/Center in College of H&S
* must provide value
Dean's Office Department of African American Studies Department of Biology Department of Chemistry Department of English Department of Forensic Science Department of Gender, Sexuality and Women's Studies Department of History Department of Kinesiology and Health Sciences Department of Mathematics and Applied Mathematics Department of Military Science and Leadership Department of Philosophy Department of Physics Department of Political Science Department of Psychology Department of Sociology Department of Statistical Sciences and Operations Research Economics (in H&S) Center for Culture Experiences in Prevention Center for the Study of Tobacco Products Clark-Hill Institute for Positive Youth Development College Behavioral and Emotional Health Institute Humanities Research Center da Vinci Center for Innovation
Reference #3
First Name  Last Name Title Email This reference is: Organization    Â
If other, please specify:
Major Area
* must provide value
Office of the President Office of the Provost Office of the Vice President for Health Sciences Office of the Vice President for Finance Office of Institutional Equity, Effectiveness, and Success Office of Development and Alumni Relations Office of the Vice President for Research & Innovation Division of University Relations Division of Administration Division of Strategic Enrollment & Student Success Division of Athletics
VCU Police and Public Safety Facilities Management Human Resources Technology Services Environmental Health and Safety Real Estate Services Office of the Vice President
VCU Finance & Budget VCU Treasurer Government Relations Board Liaison Equity and Access Services Office of the Vice President
College of Health Professions School of Dentistry School of Medicine School of Nursing School of Pharmacy Massey Cancer Center Office of the Vice President
College of Humanities and Sciences L. Douglas Wilder School of Government and Public Affairs Richard T. Robertson School of Media and Culture School of World Studies School of the Arts School of Business School of Education College of Engineering School of Social Work VCU Graduate School VCU Honors College VCU Life Sciences VCU Libraries VCU Ombudsperson VCU University College Division of Community Engagement Division of Strategic Enrollment Management Division of Student Affairs Global Education Office Institute for Contemporary Art Online@VCU Student Success Unit Office of the Provost
Audit & Compliance Services University Counsel Office of Government Relations Office of the President
Department/Center in College of H&S
* must provide value
Dean's Office Department of African American Studies Department of Biology Department of Chemistry Department of English Department of Forensic Science Department of Gender, Sexuality and Women's Studies Department of History Department of Kinesiology and Health Sciences Department of Mathematics and Applied Mathematics Department of Military Science and Leadership Department of Philosophy Department of Physics Department of Political Science Department of Psychology Department of Sociology Department of Statistical Sciences and Operations Research Economics (in H&S) Center for Culture Experiences in Prevention Center for the Study of Tobacco Products Clark-Hill Institute for Positive Youth Development College Behavioral and Emotional Health Institute Humanities Research Center da Vinci Center for Innovation
First Name
* must provide value
First Name
* must provide value
First Name
* must provide value
Last Name
* must provide value
Last Name
* must provide value
Last Name
* must provide value
Email
* must provide value
Email
* must provide value
Email
* must provide value
Professional Title
* must provide value
Professional Title
* must provide value
Professional Title
* must provide value
Organization
* must provide value
VCU VCUHS Other
Organization
* must provide value
VCU VCUHS Other
Organization
* must provide value
VCU VCUHS Other
This reference is:
* must provide value
My dean or vice president My direct supervisor A colleague/leader
This reference is:
* must provide value
My dean or vice president My direct supervisor A colleague/leader
This reference is:
* must provide value
My dean or vice president My direct supervisor A colleague/leader
This application must be complete and include the following supplemental documents by October 15, 2021 in order for your application to be considered for acceptance into the program:
*All applicants must submit three references and ensure completed references are submitted using the appropriate reference form. If you are supervised directly by your dean/vice president, then submit one letter from that person and two from other colleagues/university leaders.
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