Guiding Leaders Registration Form

All women dentists, including practice owners and associates, with 5+ years of experience are welcome to apply.

Submission must include all elements listed below to be considered for Guiding Leaders:
1. Application form
2. CV/resume (optional)
3. 90-second video (required)
  - Include your name
  - Describe what you seek to gain from the Guiding Leaders program
  - Discuss why the committee should select you as a 2023 Guiding Leaders participant
4. Terms of agreement consent
* Denotes required field
To save your application or return to it at another time, click the "Save and Continue Later" button below.
GENERAL BACKGROUND INFORMATION
Name*

First NameLast Name
Email*

Confirmation Emailexample@example.com
Phone Number (Mobile)*
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dental Practice Name*
Dental Office Phone Number
Dental Office Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dental Specialty*
Please fill in your specialty.*
Are you currently practicing?*

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?
If "Other," please describe*
Please enter the name of the person who directed you to this application*

ABOUT ME

Please limit each response to 250 words.
What are you most passionate about in dentistry? Whether it's esthetics, sleep, digital dentistry, implants, crowns & bridges, or removables, we would love to know what inspires you and why.*

0/250
Where do you envision your career in the next 5-10 years?*

0/250
Where did you go to school for dentistry?*

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

0/250
Please list at least two CE Courses you completed in 2022.*

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

0/250
Please list any accolades or achievements you have received.*

0/250
Please list your publications.

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

Cancelof
VIDEO SUBMISSION

Please upload a video that is 90 seconds long or shorter. Your video must include:
- Name
- What you seek to gain from Guiding Leaders
- Why the committee should select you as a 2023 Guiding Leaders participant
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, .wmv, .flv, .avi, .avchd, .webm, .html, .mpeg-2
Maximum file size: 1GB
UPLOAD VIDEO

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TERMS OF AGREEMENT
- Each Participant agrees to attend all sessions throughout the year.
- Participant is responsible for airfare and hotel accommodations.
- If more than one session is missed, the Participant will be terminated from the program.
- The program is all in person. The time commitment for coursework outside of the program is approximately 10 hours per month.
Please verify that you are human*
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