Guiding Leaders Registration Form

GENERAL BACKGROUND INFORMATION

Please note: All sessions are held in person at the Glidewell campus in Irvine, CA.
Attendance is mandatory, and participants must commit to all dates to be accepted into the program.
Name*

First NameLast Name
Email*

Confirmation Emailexample@example.com
Phone Number (Mobile)*
Format: (000) 000-0000.
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dental Practice Name*
Dental Office Phone Number*
Format: (000) 000-0000.
Dental Office Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dental Specialty*
Please fill in your specialty.*
YesNo
How many years have you been a practicing dentist?*
Dental License Number*
Do you have a Glidewell account? If so, please provide your account number.
How did you hear about the Guiding Leaders program?*
Please enter the name of the person who directed you to this application
If "Other," please describe*

ABOUT ME

Please limit each response to 250 words.
What are you most passionate about in dentistry? We would love to know what inspires you and why. *

0/250
What are your 5-year professional goals?*

0/250
How have you continued learning and growing professionally since completing dental school?*

0/250
In what ways would you like to see Guiding Leaders help you grow professionally and personally?*

0/250
Please list any professional organizations you are affiliated with including dates of involvement.*

0/250
Please list your publications, if any.

0/250
Have you ever worked with an executive coach? If yes, are you currently working with an executive coach?*

0/250
What areas are you interested in focusing on during coaching?*

0/250
Is there any additional information you want the selection committee to know about you?

0/250

CV / RESUME (OPTIONAL)

Please upload a current copy of your CV/resume. Your CV/resume must include:
- Career experience
- Educational history after high school
- Professional organizations including dates of involvement
- Awards/achievements
- Leadership experience/roles
- Any published work
- Two professional references including name, phone number and email address
Accepted file types: .pdf, .doc, .docx, .jpg, .jpeg, .png
Maximum file size: 10.6MB
UPLOAD CV / RESUME

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VIDEO SUBMISSION (Requirement)

Please upload a video that is 90 seconds or less. In the video, state your name and pick two of the following questions to answer:
1. What shift are you hoping this program helps you make, in your career, your leadership, or your life?
2. Think about a leadership challenge or recurring pattern you want to break. What is it, and what do you hope to do differently by the end of Guiding Leaders?
3. Guiding Leaders is designed to stretch you. What part of your leadership style, mindset, or communication are you most ready to examine or improve?
4. When you picture yourself nine months from now, after finishing Guiding Leaders, how do you plan to give back to dentistry?
Tips for Making a Quality Audition Video:
- Record in a quiet, well-lit area.
- Make sure your voice is clear and audible. Sit close to your phone or camera to get better sound quality.
- Stabilize your phone or camera so you capture a steady shot.
- Position the camera at eye level and situate yourself properly within the frame.
- Make sure you are in focus.
- Remember to smile and have fun!
- Review video before uploading.
In the event your video file fails to upload, please email it separately to guidingleaders@glidewell.com.

Accepted file types: .mp4, .mov
Maximum file size: 1GB
UPLOAD VIDEO

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TERMS OF AGREEMENT
- Each participant commits to actively participate in all in-person and virtual (mentoring and executive coaching) sessions.
- Participant is responsible for airfare and hotel accommodations.
- Any participant is liable for non-refundable reservations made on their behalf.
- The program is almost entirely in person. The time commitment for coursework outside of the program is approximately 10 hours per month.
MEMORANDUM OF UNDERSTANDING

If you are accepted into the Guiding Leaders program, you will need to adhere to the following program agreement. A Guiding Leaders program representative will reach out to you with instructions regarding how to sign this document. No action is required at this time.
Please verify that you are human*
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