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Dialogue to Action – Facilitator form
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What We Do
Racial & Social Justice
Dialogue to Action
Dialogue to Action – Facilitator form
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RSJ Dialogue to Action Facilitator form
For facilitators and participants.
Name
First
Last
Email
*
Main Phone
*
Second Phone
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Gender identification
Race/Ethnicity - Please check all that apply
Asian
Black African Descent
Caucasian
Hispanic/Latinx
Native American
Pacific Islander
Other
Religion
Please select
Catholic
Protestant
Muslim
Jewish
Other
None
Education
Please select
Less than high school
Some High School
High School Graduate
Some College
College Graduate
Post Graduate
Marital Status
Please select
Single
Married
Divorced
Disabilities
Yes
No
Training
I have been through YWCA training
I will make the training in Wilmington on August 17, 2019 9 AM - 5 PM
I am unable to make the training but am still interested.
I would like to Facilitate
Conversations around Racism
White Fragility
Where ever I am needed
I can facilitate in - Please check all that apply
N. Wilmington/Claymont
Wilmington
New Castle
Newark
Bear
Middletown
I am available on - Please check all that apply
Sunday AM
Sunday Afternoon
Sunday Evening
Monday 9 AM - 11 AM
Monday 6PM - 8 PM
Tuesday 9 AM - 11 AM
Tuesday 6PM - 8 PM
Wednesday 9 AM - 11 AM
Wednesday 6PM - 8 PM
Thursday 9 AM - 11 AM
Thursday 6PM - 8 PM
Friday 9 AM - 11 AM
Friday 6PM - 8 PM
Saturday AM
Saturday Afternoon
Saturday Evening
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