2021 HOTM Facilitator Training Program Application

Holistic Empowerment and Self-Defense Facilitator ****

Application of Interest for Spring, 2022 Training
Name:*

Indigenous NameEnglish Name
Email Address:*
Mobile Phone:*

Area CodePhone Number
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birthdate:*

MonthDayYear
Gender Identify:*
If you choose other: please describe in notes below.
Partnership Status:*

SingleHave a PartnerDivorcedOther
Number of Children or Dependents:*

None12 or more

Emergency Contact Information
Name:*

Indigenous NameEnglish Name
Email Address:*
example@example.com
Mobile Phone:*

Area CodePhone Number
Relationship *
Do you acknowledge the listed individual as your Emergency Contact and the person may be contacted by HOTM?*

I Agree
Tell Us More About Yourself
What is your Tribal/First Nation affiliation(s)?:*
Type your response here.
Why are you applying to this program (300 words or less)?:*
Type your response here.
Has MMIWG impacted you personally? If so, how? (300 words or less)?:*
Type your response here.
Please tell us how you heard about HOTM or who referred you to us? (300 words or less)?:*
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List four strengths you have that would make you a good candidate for this training:*
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Have you read the description of the training on the HOTM website thoroughly? Yes/No:*
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List four modules that you are most interested in learning more about:*
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Tell us about any previous education or training you have (High School, College, Other Trainings?:*
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Do you have experience working with Youth, Elders, Recovery, Trauma, or any groups not listed? Please Describe :*
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Do you have any experience teaching? Please Describe :*
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Tell us how you think Empowerment and Self-Defense training would help you or your community? :*
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What about HOTM inspires you? *
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Do you want to take the training for 1) Personal Growth 2) To become a Facilitator and hold HOTM gatherings in your Community or 3) Both? :*
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If you answered 2 and/or 3 above, please tell us why you want to become a Facilitator in your Community? :*
Type your response here.
Why do you believe that Empowering Indigenous Women will help end MMIWG? :*
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Please share a little about your personal growth intentions? *
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Please share a little about your ideas for Facilitating gatherings in your community. *
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Please share with us any accomplishments, personal characteristics, or experiences that make you a great fit for this training? Don't be shy! Tell us why you're awesome! :*
Type your response here.
Do you practice Traditional ways, Pray and/or Meditate or have any other ways that you take care of yourself? Please describe :*
Type your response here.

If Employed, Name of Employer:
Current Position and/or Hours of Work per week:

Commitment & Access
Can you commit to the Schedule and Save the Dates listed on the website?*
Choose one from Drop down Menu
Will you have access to a computer good internet/Wifi services for the full duration of the program?*
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How do you want to cover the costs of your training?*
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How do want to participate in the Retreat?*
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Upload an image of yourself or a headshot*

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IMPORTANT INFORMATION FOR OUR APPLICANTS:

If accepted into the program, you will need good access to WiFi to use video & sound in order to take this virtual training. (If you yourself do not have good WiFi services and still would like to take the training, see if your Tribal office, local school or community center would allow you to use space during training hours.)

You will need to be on time for meetings, and be able to commit to attending ALL virtual sessions

It is very important that you are able to attend the Destination Retreat as it will hold within it, much of the curriculum that HOM wants to impart to the trainees.

We understand that sometimes there are circumstances beyond our control. However, if you miss more than 3 virtual sessions during the course of the training, you will likely need to stop the training with a possibility of joining a future training.

If you have to end the training for any reason, fees will not be refunded to you or your sponsor. If you are able to join a future training, a portion of the sponsorship funds will be applied to that future training.
Signature: Sign your name with touch pad or mouse. Signing your name constitutes an electronic signature:*

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Holistic Empowerment and Self-Defense Facilitator ****