April Facilitator Training Application |

April 12-14, 2019 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

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?

Special Accommodations? Specify:

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?

4. 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

How many times?

Date you last served as RACE TALKS facilitator

5. Facilitation Experience

Please tell us about the skills and training that you bring to facilitation.

* Have you completed another facilitator training on racism?

Yes

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

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.

6. Mediation Experience

Please tell us about the skills and training that you bring to mediation.

* Have you completed mediation training?

Yes

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

7. 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

* I will attend all sessions of training.

Yes

* I will be on time for all sessions and activities and stay the entire session.

Yes

* I will be attentive and engaged, participating in discussions and activities.

Yes

* I will be open to learning new and different things about myself and about people not like me.

Yes

* I will be open to learning and trying out new skills.

Yes

* I will commit to one year of facilitator service to RACE TALKS, where I will attend and facilitate ten (10) RACE TALK sessions.

Yes

* 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

* 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

If you are under 18 years old, you need to have a parent or guardian consent to your participation. Please have them fill out their name and check the box to indicate their consent.

Name

Yes, they have my permission.