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 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
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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Dialogue to Action – Facilitator form

DTA Facilitator Application

Statement of Commitment