Shatterproof Family Program Instructor Application

Before you begin the application process, please review these FAQs, which include information regarding the $1,250 program fee.

Family Support Program Facilitator Application

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Contact Information

First Name

MI

Last Name

Email

Phone

Additional Contact Information

Address Line 1

Address Line 2

City

State

Postal Code

Shatterproof Involvement & Volunteer Experience

Are you a current Shatterproof Ambassador

YesNo

Are you a licensed Clinician?

YesNo

State & License #:

Have you ever been a facilitator/presenter?

YesNo

Please write a brief overview of your experience

Are you available approximately 3-4 hours per week?

YesNo

Are you willing to commit to facilitating for at least one year?

YesNot at this time

If you're not able to commit to the weekly hours or cannot commit to a full year, it may not be a good fit at this time. To discuss your situation individually, please contact Anne De Santis Lopez at alopez@shatterproof.org.

Tell us more about you

Why would you like to become a Shatterproof Family Program Facilitator?

How did you hear about this program?

If you answered "Other," please describe:

Summarize your special skills and qualification applicable for group facilitation:

Previous Volunteer Experience

Have you volunteered for other Shatterproof Events? (Select all that apply)

Shatterproof Challenge RappelShatterproof Rise Up Against Addiction 5K Walk/RunShatterproof Golf ClassicOtherI've never volunteered for Shatterproof

If you answered "Other," which event or in which capacity?

Please summarize your previous volunteer experience with other organizations:

Agreement & Signature

By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that if I am accepted as a facilitator, any false statements, omissions, or other misrepresentations made by me may result in reconsideration of my application.

Select Yes to agree

Yes

Full Name

Date

OUR POLICY

It is the policy of this organization to provide equal opportunities without regard to race, color, religion, national origin, gender, sexual preference, age, or disability.

On behalf of Shatterproof we thank you for completing this application form and for your interest in becoming a Shatterproof Family Program Facilitator.

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Contact Information

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