Expand My Reach as a CREATOR!

Name*

First Last

What is the opportunity?

Name of the Organization*

Address of Organization

Type of Setting*

Description of Population*

Why do you think this opportunity is a good fit for the CREATORS Program?*

Please tell us more about this opportunity:*

	Yes	No
Would the participants be a new group/unit/set of clients within your organization?
Would the participants be a type of population with whom you don't typically work?
Would the participants be interns or staff of your organization?
Would the participants have to pay to participate in the workshops?
Would you receive any additional compensation to lead these workshops?

It is important that both you and your participants are safe during your workshop. We want to make sure that if someone were to get hurt during the workshop (anything from a glue gun burn to triggering a mental health issue), you would not be held personally liable. Additionally we want to make sure that should something happen to you (anything from falling down the stairs to a participant hurting you), that you would be protected. PeaceLove's insurance does not cover you in these circumstances.*

	Yes	No
Would you be covered under the organization's insurance policy as a current employee, volunteer, or presenter?

Do you already have a date in mind for this opportunity?*

No
Yes

The date(s) are*

Approximately how many individuals would participate in the session?*

Do you expect this to be a one-time opportunity or do you see it possibly developing it into a longer term and greater impact situation?*

Who would be our contact person for this opportunity? We may reach out to this person about being involved in the CREATORS Program. We can also send this person an impact report about your work as a CREATOR if that is desired.

Name*

Organization*

Position*

Email*

Phone*

Other information we should know about this person?

Anything else we should know?

Expand My Reach as a CREATOR!

Expand My Reach as a CREATOR!

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