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Dialogue to Action – Facilitator form
Home
What We Do
Racial & Social Justice
Dialogue to Action
Dialogue to Action – Facilitator form
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DTA Facilitator Application
For facilitators and participants.
Name
*
First
Last
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
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Montana
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New Hampshire
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Virginia
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West Virginia
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Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Main Phone
*
Second Phone
Email
*
How do you identify racially or ethnically?
*
How do you identify your gender?
Are you under 18? (Youth)
Yes
No
Why do you want to become a facilitator for YWCA’s Dialogue to Action (DTA), Conversations about Racism?
*
Have you participated in a DTA Conversation about Racism group discussion previously?
*
Yes
No
Have you ever facilitated conversations on racism?
*
Yes
No
Have you completed training for facilitating conversations before?
*
Yes
No
Do you have other relevant experience? (please specify)
I can attend training on
September 9th & 10th from 6-9pm (1st choice)
September 22nd & 23rd (2nd choice)
Statement of Commitment
If chosen to become YWCA Delaware Facilitator for Conversation about racism, I understand there are expectations to promote healing and have healthy racial dialogue. I agree to the following:
I will do any pre-work assigned to help me prepare for facilitator training
*
Yes
No
I will attend all sessions of training
*
Yes
No
I will remain attentive and engaged, participating in discussions and activities during training
*
Yes
No
I will be open to learning and trying out skills
*
Yes
No
I will commit to facilitate at least 2 sessions (6 weeks/2hrs each) of DTA, Conversations about Racism over the next 18 months once training is complete.
*
Yes
No
I will make time to prepare and debrief with my co-facilitator during the time of facilitating a group
*
Yes
No
I agree not to promote and utilize this program without giving credit to YWCA DE and Everyday Democracy
*
Yes
No
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