CREATORS Application

General Information

Thank you for your interest in the CREATORS Training to facilitate PeaceLove workshops!

Full Name*

Nickname (if applicable)

How did you hear about the CREATORS Training, who referred you ?*

I am interested in the following training:*

Virtual 2 day Training November 7-8 (9:30a-4:30p EST)

The Virtual Training cost is $4,000*

My organization is paying for my training.
I'm applying for a partial scholarship.

This price covers 2 full days of experiential training, CREATORS manual with step by step guidance for the facilitation of 4 workshops, all workshop supplies and support materials for the next year & possibly beyond, ongoing support and engagement, invite to CREATORS Team Builders and access to the CREATORS Exchange community.

Employment

Organization/Company*

Job Title*

How would you categorize your organization?*

School
VA
Hospital/Healthcare
Behavioral/Mental Health Program
Community
Corporate
Substance Use Treatment
Justice System/Corrections

Please choose one of the following that best fits the setting of your organization:

Work Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Work Email*

Work Phone*

Dates of Employment*

(MM/YYYY - MM/YYYY)

Do you expect to have a change of workplace or career in the next year?*

Yes
No

Supervisor’s Name*

Supervisor’s Position*

Supervisor’s Email*

Supervisor’s Phone*

What experiences have you had as a teacher, mentor, or group facilitator?*

Personal and Contact Information

Home Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Personal Email*

Personal Phone*

Do you have a mailing preference?*

Yes, please use my work address
Yes, please use my personal address
Either is fine

Do you have a phone preference?*

Yes, please call my work phone
Yes, please call my personal phone
Either is fine

Do you have an email preference?*

Yes, please use my work email
Yes, please use my personal email
Either is fine
Please send to both of my email addresses

What is the best way for us to contact you?*

Please use my preferred phone
Please use my preferred email
Either is fine

Can we add you to our mailing lists for occasional newsletters, updates & happenings around the PeaceLove Studio?*

Yes, Sign me up!!!
No Thanks

Birthday*

Please list any food allergies or dietary restrictions

Gender Pronoun

Emergency Contact Name*

Emergency Contact Phone*

Relation to You*

Questions about your Population

Which of the following age groups best describes your typical population? Select any that apply*

Children (ages 0-7)
Youth (ages 8-24)
Adults (25 +)
All ages/Families

Please indicate the number of individuals your organization serves:*

Less than 100 individuals per year
Between 100-500 individuals per year
Between 500-1000 individuals per year
Over 1000 individuals per year

Please indicate the number of individuals you personally serve:*

Less than 100 individuals per year
Between 100-500 individuals per year
Between 500-1000 individuals per year
Over 1000 individuals per year

Please indicate the average size of the groups you work with at a given time:*

Small (1-5)
Medium (6-10)
Large (11-20)
Very Large (Over 20)

What are the types of life experiences of those you serve? (check all that apply)*

Select All
Child Abuse/Neglect
Community Violence
Domestic Violence
Foster Care
Grief/Loss

About what percentage of your population has access to health insurance?*

100%
50%
Under 50%

About how many individuals do you serve each year that do not have access to food and basic necessities?*

Less than 100 individuals per year
Between 100-500 individuals per year
Between 500-1,000 individuals per year
Over 1,000 individuals per year

Approximately how many individuals are directly affected by poverty within the population you serve?*

Less than 100 individuals per year
Between 100-500 individuals per year
Between 500-1,000 individuals per year
Over 1,000 individuals per year

What do you love most about the individuals you serve?*

Is there any other information you would like us to know about you and/or the individuals you serve?

Agreement

Please read the following agreement and sign below.

I understand the two day training is intended to equip me with skills for facilitation of expressive arts experiences. I am aware that though it will include opportunities for self-reflection and individual growth, the focus of the training is curriculum mastery and professional development. I understand that this experience is not personal therapy or a wellness retreat.

Signature*

Type your name below to sign and verify your agreement to the above statement regarding the CREATORS Training.

I have read and understand the qualifications, time commitments, and expectations for being a PeaceLove CREATOR. I acknowledge that the information contained in this application is factual and is a realistic assessment of my abilities. I understand that falsification of information on this application may result in my dismissal from the CREATORS Program. I authorize PeaceLove to verify my information and to contact my supervisor references. If selected as a CREATOR, I agree to maintain the integrity of the program by adhering to the curriculum and structure established by PeaceLove. Additionally, I understand that becoming a PeaceLove CREATOR would not make me a licensed therapist.