NCCJ FaciliTrainer Certification Program Participant Questionnaire

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PERSONAL INFORMATION

Name

First Name

Last Name

Organization

Title/Position

Work Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Work Phone

(###)

###

####

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home or Cell Phone

(###)

###

####

Preferred Method of Communication

DEMOGRAPHIC INFORMATION

Assigned Sex

Gender Identity

Sexual Orientation

Birth Date

YYYY

Current Class Status

Childhood Class Status

Race

Ethnicity

Religion

Ability Status

QUESTIONS

Please explain your interest in attending the FTCP program:

Please describe your leadership and/or group facilitation experience:

Have you attended diversity trainings before? If yes, what was your experience with these trainings? How in-depth did you feel these trainings went?

Please describe your experience with anti-oppression work, if any:

How would you describe yourself in terms of human diversity?

How would you describe your knowledge of the following the identities class, race, biological sex, religion, gender, sexual orientation, ability, age, ethnicity, size/look (personal experience, classes, workshops, readings, etc)? What about your comfort level with each of these identities?

Which (if any) other NCCJSTL programs have you attended?

What do you hope to get out of this program/what do you want the outcomes to be?

Anything else you would like us to know about you?

Do you have any food allergies or dietary restrictions we should know about or need accommodation for?

Do you having any lodging accommodations that we should know about?