Application for Foundations of Facilitation Training and/or Cuddle Party Facilitator Training Program

I would like to attend:

 Mar 2-4, 2012 at CP HQ, Montgomery, AL

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:
Name I like to be called:
Home Address:
Phone Number:
Times you can be reached at these numbers: Home: Cell: Work:
Email Address:
SKYPE Name:
Birthdate: Month: Day: Year:
Gender:
Employment: /
Choose which represents the highest level of education you have completed:
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 / Expires:

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.  I agree
Date: Month: Day: Year: