Your Name:
*
First Name
Last Name
Email:
*
example@example.com
Your Course
Did you work with a co-facilitator?
*
Yes
No
Co-Facilitator's Name:
First Name
Last Name
Did you lead your course online or in-person?
*
Online
In-person
Where did you lead your course?
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Course Start Date:
*
-
Month
-
Day
Year
Date Picker Icon
Course End Date:
*
-
Month
-
Day
Year
Date Picker Icon
Session Start Time:
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
05
10
15
20
25
30
35
40
45
50
55
Minutes
AM
PM
AM/PM Option
Session End Time:
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
05
10
15
20
25
30
35
40
45
50
55
Minutes
AM
PM
AM/PM Option
Your Service Project
Who did the project serve?
*
Youth (up to the age of 18)
Populations facing poverty or homelessness
LGBTQ+ community
Specific racial/ethnic/religious group
Individuals with mental illness or disability
Individuals with physical illness or disability
Refugees, asylum seekers and/or migrants
Veterans and active duty military
Survivors of sexual assault and/or gender-based violence
Survivors of physical abuse or violence
Prison-based or incarcerated populations
First responders (police, fire, paramedic)
Animals at an animal rescue or shelter
Other
Number of individuals served:
*
Please describe your group's service project:
*
Did you partner with or support another nonprofit organization/project for your service project?
*
Yes, we partnered with another nonprofit organization
Yes, our service project supported another nonprofit
No
Name of nonprofit organization/project:
Nonprofit organization's website URL, if applicable:
If you acquired any donations for your service project, please give details below:
For each donation, include the donation type, quantity, and donor
What was your most memorable moment or experience from the service project?
*
Did you take any photos (or screenshots) of the service project?
*
Yes
No
Please use the button below to upload any photos of the service project, which you have permission to share:
Browse Files
Cancel
of
Please use the space below to record testimonials, thoughts, or feedback from participants, relating to their experience of the service project:
Please use the space below to record any other thoughts or comments you wish to share, relating to the service project:
Course Participation
How many participants enrolled in your course?
*
Were all participants present for the entirety of all scheduled sessions?
Yes
No
Please describe the circumstances that led the participant(s) to miss a scheduled session:
Did any participants drop out of your course?
*
Yes
No
Please describe why they dropped out, if known:
Did you have to ask any participants to leave the course?
*
Yes
No
Please describe the circumstances that led to you asking the participant(s) to leave:
Participant Engagement
Participants consistently attended sessions (excluding any extenuating circumstances).
*
1
2
3
4
5
Strongly disagree
Strongly agree
1 is Strongly disagree, 5 is Strongly agree
Participants were actively engaged during discussions and activities.
*
1
2
3
4
5
Strongly disagree
Strongly agree
1 is Strongly disagree, 5 is Strongly agree
Participants seemed interested in the content of the program.
*
1
2
3
4
5
Strongly disagree
Strongly agree
1 is Strongly disagree, 5 is Strongly agree
Participants built friendships and a sense of community among one another.
*
1
2
3
4
5
Strongly disagree
Strongly agree
1 is Strongly disagree, 5 is Strongly agree
Participants were able to express their thoughts, feelings, and experiences.
*
1
2
3
4
5
Strongly disagree
Strongly agree
1 is Strongly disagree, 5 is Strongly agree
Participants reported improvements in their relationship with food, body, and self.
*
1
2
3
4
5
Strongly disagree
Strongly agree
1 is Strongly disagree, 5 is Strongly agree
Other
Did you take any other photos (or screenshots) during the course?
*
Yes
No
Please use the button below to upload any photos which you have permission to share:
Browse Files
Cancel
of
Please use the space below to share any other relevant information about how your course went:
Submit
Should be Empty: