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Application for Foundations of Facilitation Training and/or Cuddle Party Facilitator Training Program I would like to attend: Sep 24-26, 2010 in Toronto, ON Canada Oct 01-03, 2010 in DC/Mid-Atlantic area, IL Jan 21-23, 2011 in Atlanta (Area), GA Feb 25-27, 2011 in Oakland, CA I cannot attend a live training, and would like to enroll in the Virtual Training Option: To be accomplished by Virtual Training teleconference and web conference training modules. I am interested in: Training only (I want to gain the skills offered in this training program but do not want to run Cuddle Party events myself.) Certification as a Cuddle Party facilitator (I want to run official Cuddle Party events.) Training, and maybe also certification (I want to gain the skills offered in this training program, and am not sure yet if I want to become certified.)   Name: L a s t F i r s t Middle Name I like to be called: Home Address: Street, PO Box City State ZIP Phone Number: Home C e l l Work Times you can be reached at these numbers Email Address: SKYPE Name: Birthdate: Month 1 2 3 4 5 6 7 8 9 10 11 12 Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 Gender: male female transgendered Employment: Job Title Company Choose which represents the highest level of education you have completed: less than high school graduate high school graduate some college college graduate post graduate work post graduate degree List any degrees / awards / honors you have received: List any training programs or coursework you have participated in: Please list the top three principal committments in your life currently, in order of importance: 1. 2. 3. Please state the main reasons you are interested in taking the Cuddle Party facilitator training: If you are interested in receiving certification as a Cuddle Party Facilitator, please answer the following questions: Please look into your own life and illustrate that you possess each of the characteristics mentioned in the following statements. (450 character maximum for each) A. You are able to listen to people and hear their underlying concerns. B. You already possess well-developed communication skills. C. You create positive environments of non-judgement and acceptance. D. You can handle telling people 'No', politely and firmly even when they are angry or being difficult with you. E. You take initiative and show leadership. F. You have a high level of commitment to integrity. G. You actively demonstrate a commitment to contribute to others. 1. Are you certified in CPR and First Aid? Yes No If yes, which? Red Cross CPR. Expires: Amer. Heart Assn. Expires: Red Cross First Aid. Expires: Other. Specify: 2. Have you ever been convicted of a felony? Yes No If yes, please explain: 3. Are you currently taking any drugs for a mental condition or mood-altering drugs? Yes No 4. Please state the main reasons you are interested in facilitating Cuddle Party events: 5. Please provide the names for at least two people who can provide references for you. Name Phone Number Email Address Relationship All statements contained in this application are true to the best of my knowledge. Yes I have read and understand the Terms and Conditions related to this agreement. Date: Month 1 2 3 4 5 6 7 8 9 10 11 12 Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2009 2010 2011 back to top