Name:

Address:

City:

State:

Zip:

Home Telephone:

Work Telephone:

E-mail:

Date of Birth:

Month:     Day:     Year:

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 certified in CPR
        Certification Expiration Date:    
No, I am not certified in CPR

Select One:

Yes, I am certified in First Aid
        Certification Expiration Date:    
No, I am not certified in First Aid

MY WOMAN WITHIN INITIATION:

      Month:     Day:     Year:

 Location:

Select One:

Yes, I have completed the One Day Staff
        Training

      Month:     Day:     Year:

 Location:

No, I have not completed the One Day Staff
       Training

Select One:

Yes, I have completed the Women Empowering
        Women Workshop

      Month:     Day:     Year:

 Location:

No, I have not completed the Women
       Empowering Women Workshop.

Select One:

Yes, I have completed the Empowerment
        Circle Manual in an 8-week or Intensive format.

      Month:     Day:     Year:

 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 Woman 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 Request

Languages:

Languages other than English that I speak fluently::
  

Through Staffing I hope to gain:
 

I support my ongoing 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 Staff Coordination for Woman to Woman, Midwest ASAP.

YOUR SIGNATURE:
(Your typed name here constitutes your signature)

 Your Name:
  

  Month:     Day:     Year: