Application - STEM Leadership and Advocacy Academy

Section 1: Personal Information

Full Name

First

Middle

Last

Date of birth

Email Address

Email

Confirm Email

Mobile Number

WhatsApp enabled if available

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Residential City/Town

Section 2: Demographic Information

Gender Identity

If self-describe, please specify

Nationality

Languages Spoken

Section 3: Professional Background

Highest Qualification

Please specify

Field of Study

Profession

Current Institution or Organization

Current position

Relevant Technical Skills

Section 4: Professional and Leadership Profile

Where do you want to lead change?

Briefly describe your professional or academic experience relevant to STEM.

Describe a situation where you took on a leadership role or initiative (formal or informal). What did you do, and what was the outcome?

What is one challenge affecting women in STEM in your environment? How have you observed or experienced this, and what do you think needs to change?

Describe a leadership challenge or setback you have faced. What did you learn from the experience?

Why are you applying to the STEM Elevate Leadership & Advocacy Academy, and what change do you hope to achieve during and after the programme?

Section 5: Consent and Confirmations

How comfortable are you with virtual learning and technology tools?

	Very comfortable	Somewhat comfortable	Not comfortable
Level of comfort	Very comfortableLevel of comfort Very comfortable	Somewhat comfortableLevel of comfort Somewhat comfortable	Not comfortableLevel of comfort Not comfortable

Which digital tools are you comfortable with?

Would you like to mentor future STEM Elevate participants after completion?

Are you able to commit 8–12 hours per month for 6 months?

Yes I can
No I cannot

& affecting or

Consent to participate in M&E surveys and evaluations

Yes I consent

Consent to Use Data and Images

I agree

I consent to the use of my data and professional headshot for programme administration, mentorship matching, baseline monitoring, and publication profiles, in line with the STEM Elevate initiative’s mission.

Name, Address and Phone number of Referee

Additional Comments or Questions (optional)

Signature

Enter your full name

Date

Enter today’s date

STEM Elevate Leadership & Advocacy Academy

Application Form (2026 Cohort)

Section 1: Personal Information

Section 2: Demographic Information

Section 3: Professional Background

Section 4: Professional and Leadership Profile

Section 5: Consent and Confirmations