Spirit of Leadership Facilitator Application

Facilitator Application:

First Name:

Last Name:

Phone:

Email:

Title:

Organization:

Address:

City:

State:

Zip Code:

Referred By:

Professional Reference

First Name:

Last Name:

Organization:

Phone:

Email:

Personal Reference

First Name:

Last Name:

Organization:

Phone:

Email:

Relation:

How did you hear about the Spirit of Leadership Program?

Do you speak any languages other than English?

List any community service organizations or clubs to which you have belonged:

Previous Volunteer Experience

List any hobbies or special interests you have:

Have you had any past or do you have any current involvement with the Health and Human Services Agency (Child Protective Services)? If yes, please explain

Have you ever been convicted of a crime in this or any other state? If yes, please explain.

Workshop Proposal

Workshop Title

Workshop Description (Including description of content and interactive exercises)

Have you ever presented your workshop to middle and/or high school youth?

Yes
No

Describe your experience facilitating small group discussions with middle and/or high school aged students

Do you have a video demo DVD?

Yes
No

If so, please provide the web link or mail to:

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