WOMAN WITHIN  STAFFING APPLICATION FORM

NAME:	__________________________________________________
ADDRESS LINE 1:	__________________________________________________
ADDRESS LINE 2:	__________________________________________________
CITY, STATE, ZIP:	__________________________________________________
HOME TELEPHONE:	__________________________________________________
WORK TELEPHONE:	__________________________________________________
EMAIL ADDRESS:	__________________________________________________
DATE OF BIRTH:	__________________________________________________
HEALTH CONDITIONS that might affect my ability to staff, including my ability to lift and carry:	__________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________
SPECIAL ACCOMMODATIONS needed to Staff:	__________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________
SELECT ONE:	____ Yes, I am a health care professional   Please specify:____________________________________________ ____ No, I am not a health care professional
SELECT ONE:	____ Yes, I am a certified in CPR.  Expiration Date:_________________ ____ No, I am a not certified in CPR
SELECT ONE:	____ Yes, I am a certified in First Aid.  Expiration Date:_______________ ____ No, I am a not certified in First Aid
MY  WOMAN WITHIN INITIATION:	Date:_______________           Location:_____________________________________________
SELECT ONE:	____ Yes, I completed the One Day Staff Training.              Date:______________    Location:________________________ ____ No, I have not completed the One Day Staff Training.
SELECT ONE:	____ Yes, I completed the Women Empowering Women Workshop.              Date:______________    Location:________________________ ____ No, I have not completed Women Empowering Women Workshop.
SELECT ONE:	____ Yes, I completed the Empowerment Circle Manual in an 8-week            or intensive format.               Date:______________    Location:________________________ ____ No, I have not completed the Empowerment Circle Manual in an            8-week  or intensive format.
PRIOR STAFFING EXPERIENCE:	Number of times I have staffed a Woman Within Initiation:  ___________
FACILITATION TRACK:	Level on Women Within facilitation track:  ___________
I WANT TO BE CONSIDERED FOR THE FOLLOWING STAFF ASSIGNMENTS:	____ Ritual                    ____ Nurturer   ____ Music                    ____ Team Leader ____ Facilities              ____  Assistant Team Leader ____ Room                   ____  Small Group Leader ____ Timer                    ____  Facilitation Team Member ____ Snacks ____ Safety                    ____  No Specific Requests
LANGUAGE(S) OTHER THAN ENGLISH THAT I SPEAK FLUENTLY:	_______________________________________________________ _______________________________________________________
THROUGH STAFFING I HOPE TO GAIN:	_______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________
I SUPPORT MY ONGOING AND DEVELOPMENT BY:	_______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________
PLEASE SELECT THE DATES OF EACH  WEEKEND TRAINING YOU ARE APPLYING FOR: (2008)	____ May 2 - 4, Chicago/Milwaukee (Delavan, WI) ____ June 20 - 22, Columbia,IL ____ Sept 12 - 14, Chicago/Milwaukee (Delavan, WI) ____ Oct 3 - 5, Louisville/Cincinnati (Nazareth, KY) ____ Nov 7 - 9, Chicago/Milwaukee (Delevan, WI)

I commit to be accountable by keeping a record of the Initiation dates I requested. If I am no longer available to staff the Weekend Training(s) which I requested, I commit to inform Mary Ann Armour, Director of Training for Woman to Woman, Midwest ASAP. .

Your Signature:

Name:  __________________________________________________ Date:    __________________

Mail to: Mary Ann Armour Director of Training Woman to Woman Midwest 1010 South Carolina St Louisiana, MO 63353 Phone: 573.754.3131 Fax: 573.754.3880