Application for FACILITATOR Training

Contact information:

Name:

Address:
City: State: Zip Code:
Telephone Number: Alternate Number
Email:
Business Name: Title/Position:

Other Information:

Previous Work or educational experience with Domestice Violence issues:

Previous Work or educational experience with Mediation/Facilitation:

Educational Background:

Other useful information/interests you care to provide:

This form will be submitted using your email client that opens automatically. You can also submit this form by printing it and mailing it to the DVSD address.

A commitment of conducting 3 future facilitations is asked.
May be used for 18.25 CEU credits

Carrie Outhier Banks, Executive Director
Domestic Violence Surrogate Dialogue
150 N. First Avenue, Suite 200
Hillsboro, Oregon 97124
(503) 846-3023