RACE TALKS Facilitator Training Application Facilitator Training Application Section One Background Information 1. Your Contact Information Name, address, phone, email * Name First Last Middle Initial * Mailing address Street Address Address Line 2 City Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State ZIP Code * Preferred Phone Number * Preferred Email Address 2. Emergency Contact Information Who should we contact in the case of emergency? * Emergency Contact Name First Last * Emergency Contact Relationship * Emergency Contact Phone 3. Demographics Gender, race & ethnicity, age, allergies * How do you identify racially or ethnically? * How do you identify your gender? * What is your preferred pronoun? * What is your age? 17-24 25-31 32-38 39-45 46-51 52-57 58-64 65+ Special Accommodations? Specify: 4. Training Availability The training is offered on three different weekends. The training dates are below. Please rank your training date preference. Select your first, second, and third preferred dates. * Please select your first preference: October 26 - 28, 2018 November 2 - 4, 2018 January 25 - 27, 2018 Choose the dates that work BEST for you. * Please select your second preference: October 26 - 28, 2018 November 2 - 4, 2018 January 25 - 27, 2018 Choose the dates that work for you. * Please select your third preference: October 26 - 28, 2018 November 2 - 4, 2018 January 25 - 27, 2018 Choose the dates that work for you. Section Two Background of Experience * Why do you want to be a RACE TALKS dialogue facilitator? Please use this space provided to describe in 100-250 words why you'd like to be a RACE TALKS dialogue facilitator. * How many RACE TALKS events have you attended in the past? 5. RACE TALKS Facilitation Experience Please tell us about the facilitation skills and training you've shared with RACE TALKS. * Have you served as a volunteer RACE TALKS dialogue facilitator? Yes No How many times? Date you last served as RACE TALKS facilitator 6. Facilitation Experience Please tell us about the skills and training that you bring to facilitation. * Have you completed another facilitator training on racism? Yes No How many times? Presenting Organization of Last Facilitator Training For which organization did you facilitate a training on racism? Completion Date of Last Facilitator Training Additional facilitator training experiences on racism Please list each training "Presenting organization/Date of Training" on a line. * Have you completed another facilitator training on diversity and equity? Yes No How many times? Presenting Organization of Last Facilitator Training For which organization did you facilitate a training on diversity and equity? Completion Date of Last Facilitator Training Additional facilitator training experiences on diversity and equity Please list each training "Presenting organization/Date of Training" on a line. Have you completed another facilitator training(s) on other related topics? Please specify. Include topic(s) of training, organization(s) you were trained by / date(s) of training completion. Do you have other relevant experiences? Please specify. Include areas of expertise, skills, specific groups you worked with, etc. * What's your experience level with facilitation? I've had experience(s) with small group facilitation. I do not have any facilitation experience. Briefly describe your experience(s), including the purpose of facilitation, description of participation, and outcomes. 7. Mediation Experience Please tell us about the skills and training that you bring to mediation. * Have you completed mediation training? Yes No How many times? Presenting Organization of Last Mediation Training Completion Date of Last Mediation Training Additional facilitator training experiences on mediation Please list each training "Presenting organization/Date of Training" on a line. Do you possess special knowledge or expertise about a particular topic that are affected by, or impact racism? Please describe briefly. Section Three Facilitator Trainee’s Statement of Commitment 8. Statement of Commitment By registering to attend facilitator training, I understand that the training involves an evaluation of my skills and readiness to facilitate. If I am approved as a facilitator, thereafter, I agree to the following: * There are pre-training assignments that will be assigned upon my acceptance. I will complete these assignments in preparation for the intensive training. Yes No * I will attend all sessions of training. Yes No * I will be on time for all sessions and activities and stay the entire session. Yes No * I will be attentive and engaged, participating in discussions and activities. Yes No * I will be open to learning new and different things about myself and about people not like me. Yes No * I will be open to learning and trying out new skills. Yes No * I will commit to one year of facilitator service to RACE TALKS, where I will attend and facilitate ten (10) RACE TALK sessions. Yes No * I will participate in two monthly team call-in sessions: A pre-session call will prepare me for each monthly dialogue; a post-session will allow me to debrief and build cohesively with fellow facilitators. Yes No * I will complete ongoing skill building assignments as they are assigned. These assigned reading and activities will support me in my growth as a facilitator in race dialogues. Yes No
