April Facilitator Training Application

April 12-14, 2019 Facilitator Training Application
Section One
Background Information

1. Your Contact Information

Name, address, phone, email

2. Emergency Contact Information

Who should we contact in the case of emergency?

3. Demographics

Gender, race & ethnicity, age, allergies

Section Two
Background of Experience
Please use this space provided to describe in 100-250 words why you'd like to be a RACE TALKS dialogue facilitator.

4. RACE TALKS Facilitation Experience

Please tell us about the facilitation skills and training you've shared with RACE TALKS.

5. Facilitation Experience

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

For which organization did you facilitate a training on racism?
Please list each training "Presenting organization/Date of Training" on a line.
For which organization did you facilitate a training on diversity and equity?
Please list each training "Presenting organization/Date of Training" on a line.
Include areas of expertise, skills, specific groups you worked with, etc.

6. Mediation Experience

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

Please list each training "Presenting organization/Date of Training" on a line.
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:

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.