2019
University of Wyoming
Collaboration Program in Natural Resources
Application Form
Due May 17, 2019
Type into each field and save your response. Submit your application by email, fax, or postal mail. Instructions on last page.
First Name
Last Name
Preferred Name
Organization
Employment
Dates
Title/Position
Work Address
Work Phone
Fax
Home Phone
Cell Phone
E-mail
Website
Home Address
Mailing Address
Home: Work:
Emergency
Contact (name
and phone)
CHECK YOUR AFFILIATION
Private Industry
Environmental Org
Community Org
Educational Institution
Other: ________________
Not Affiliated
EDUCATIONAL BACKGROUND
Grad School
Date
Degree
Under Grad
Date
Degree
High School
Date
EMPLOYMENT HISTORY
Employer
Title/Position
Date
Employer
Title/Position
Date
Employer
Title/Position
Date
OPTIONAL INFORMATION
Birth Date
Male Female
Race/Ethnicity
TUITION AND/OR TRAVEL ASSISTANCE REQUEST
All requests will be evaluated based on available funding
Tuition
Funds
Requested:
$
Travel funds
Requested:
Please add
estimated
expenditures
$
Reason for request:
PLEASE TELL US ABOUT YOURSELF
What do you hope to achieve from your experience in the Collaboration Program in Natural Resources? How
will this achievement benefit you professionally? Personally?
Please tell us about mediation or leadership development programs you have participated in the past. We are
also interested in knowing whether you have participated in the following assessments:
Myers Briggs Assessment
Leadership assessment (what type of assessment?) ________________________________________
__________________________________________________________________________________
Facilitation techniques (and the name or a description of the techniques) _____________________
__________________________________________________________________________________
Mediation or leadership development program (what did you value about the program?) _______
__________________________________________________________________________________
__________________________________________________________________________________
ATTENDANCE AND PARTICIPATION
Graduation from the Collaboration Program in Natural Resources in April 2020 is contingent on
participants attendance and involvement in the workshop sessions and fulfillment of the practicum
requirement
.
Participants who miss more than half of a session can make up the session in consultation with
faculty. Tuition is not refundable if a participant withdraws from the program (though it may be applied to a
future year). Participants should anticipate three full days per session, which includes travel time. Sessions
usually begin with a noon lunch on the first day and end at noon on the third day.
Session 1
Noon July 17 noon July 19, 2019, Lander, WY
Session 2
Noon Aug 14 noon Aug 16, 2019, Lander, WY
Session 3
Noon Sept 25 noon Sept 27, 2019, Casper, WY
Session 4
Noon Oct 30 noon Nov 1, 2019, Laramie, WY
Session 5
Noon Dec 4 noon Dec 6, 2019, Laramie, WY
Session 6 Practicum presentation and graduation
April 2020, Date and location TBD
PROGRAM COSTS
The Program tuition is $1,000. The tuition covers partial costs associated with instruction,
educational materials, assessment instruments, and other session amenities. The tuition is paid
in full at the April session. Tuition can be paid by an organization or the individual
participant. Participants are responsible for travel, lodging, and meal costs.
PARTICIPANT PLEDGE
I understand the goals and objectives of the Collaboration Program, and, if selected to participate, I will pay a
non-refundable tuition of $1000 by June 28 , 2019. I understand that the success of the Program and that of
my fellow participants depends on my participation in all workshop activities and in the practicum.
Therefore, I am willing to devote the time to this program as described in this application.
________________________________________________________________
Applicant’s Signature
EMPLOYER’S APPROVAL
I understand the time commitment required of my employee to participate in the Collaboration Program in
Natural Resources and approve of his/her absence if selected to participate.
___________________________________________
Employer’s Signature (where applicable)
Please submit completed application on or before May 1, 2019.
You will be notified of your acceptance status
as soon as possible upon receipt.
You may submit the application and pledge by email, fax, or postal mail to
the contact below:
Email: jessica.western@uwyo.edu
Fax: (307) 766-5099
Attention: Jessica Western, Ph.D.
Mail: Jessica Western, Ph.D.
Collaboration Program in Natural Resources
Ruckelshaus Institute of Environment and Natural Resources
University of Wyoming
804 E Fremont St
Laramie, WY 82072
Website: uwyo.edu/haub/ruckelshaus-institute
The Collaboration Program in
Natural Resources is made
possible by generous support
from Rocky Mountain Power.
click to sign
signature
click to edit
click to sign
signature
click to edit