Apply – OASAS Leadership Academy

Please create your account

Username*

Password*

Confirm Password*

Personal and employer information

First Name*

Middle Initial (If applicable)

Last Name*

Preferred name (If applicable)

Job Title*

Which of the following best describes the area of your work within the addictions field?*

Specify other work within the addictions field:

Organization Name*

Organization Address*

Organization City*

Organization County*

Organization State*

Organization Zip Code*

Street Address*

City*

State*

Zip Code*

Phone Number (Work)*

Phone Number (Personal) max of 10 digits*

E-mail Address*

Supervisor Name*

Supervisor Email Address*

Supervisor Phone Number*

Application

How did you learn about this Leadership Academy?*

If Other, please specify:

Were you encouraged by your supervisor to apply for this Leadership Academy?*

YesNo

Why did your supervisor encourage you to apply for the Leadership Academy?

There will be 3 in-person sessions, and 1 virtual session as part of the Learning Academy. Can you commit to attending all four sessions?*

YesNo

Attendance at all sessions is mandatory. Do you understand and agree to commit?*

YesNo

Please include a personal statement (max. 250 words) as a part of this application. This should describe your interest in attending the Leadership Academy.*

Please provide a reference as part of this application. Note that your reference should be a current or previous supervisor from your current employer, and they will be contacted via email.

Reference Name*

Reference Email*

Reference Phone Number*

Do you have OASAS Credentials?

Do you have a Dept Of Education license?

Demographics

The Leadership Academy aims to strengthen, expand, and diversify the addictions workforce by offering career advancement opportunities in the field. Collecting student demographic data helps us assess our progress toward this goal.

Participation in this section is entirely voluntary and confidential, with all data used only in aggregate. Each category also includes a "prefer not to answer" option.

Gender Identity*

Gender Identity

Legal Sex*

Do you identify as Transgender?*

Race*

Asian Origin (Select All That Apply)

Hispanic Origin (Select All That Apply)

Pacific Islander (Select All That Apply)

Primary Language*

Other Language (Select All That Apply)

Special Needs

Do you require any dietary or physical accommodations? Please explain.*

Thank you for your interest in applying to the Leadership Academy. You will be contacted with further information upon review of your application.

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