If you are human, leave this field blank.Personal InformationDIVERSITY DIALOGUE PAGE COMMUNITY FACILITATOR APPLICATIONPlease complete the application by March 5, 2021Full Name (First, Middle, Last) *Name I Prefer to be called *Home Phone *Please include your area codeCell Phone *Please include your area codeWork PhonePlease include your area codeEmail *Home Address *CountryUnited States (US)United Kingdom (UK)CanadaAustralia---AfghanistanÅland IslandsAlbaniaAlgeriaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAmerican SamoaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelauBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongo (Brazzaville)Congo (Kinshasa)Cook IslandsCosta RicaCroatiaCubaCuraÇaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqRepublic of IrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalQatarReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Martin (Dutch part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSan MarinoSão Tomé and PríncipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaWestern SamoaYemenZambiaZimbabweCityStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces (AA)Armed Forces (AE)Armed Forces (AP)American SamoaGuamNorthern Mariana IslandsPuerto RicoUS Minor Outlying IslandsUS Virgin IslandsZip codeDDD Referral Organization *(ex: Dominion Energy, VCIC, other)I will volunteer from 9:30 am – 2:30 pm on (please indicate) *Thursday, March 25Friday, March 26I prefer to be reached by *Home PhoneWork PhoneCell PhoneEmailDemographic InformationPlease provide the following demographic information. Be as specific as possible. *This information will be used to ensure that we have as diverse a community at DDD as possible.*Gender *Date of Birth *Religious Identity *Racial/Ethnic Background (check all that apply) *American Indian/Native AmericanAsian/Asian-AmericanBlack/African-American/CaribbeanLatino(a)(x)/HispanicMiddle EasternOther IdentityWhite/European AmericanIs there any other information about your identity that you would like to share (i.e. ability status, languages spoken, national origin, etc.)Medical InformationMedical Emergency Contact *Medical Emergency Contact Phone *Are any particular accommodations needed for you to be able to join Zoom by video during both the training and the program itself? *YesNoIf yes, please explainAgreement I commit to being present at: Facilitator Orientation – virtually on Wednesday, March 17 (5:30 pm to 8:00 pm) DDD– virtually on Thursday, March 25 OR Friday, March 26 (9:30am - 2:30pm) I understand that although the Virginia Center for Inclusive Communities (“sponsor”) has taken precautions to provide proper organization, supervision, and instruction for each activity, it is impossible for the sponsor to guarantee absolute safety. I also understand that each participant/volunteer shares the responsibility for safety during all activities and I assume that responsibility for myself. I waive any claim that may arise against the Board of Directors of the sponsor, and/or its employees, agents, volunteers, or lessors including those claims which may arise from the negligence of the sponsor, their Board of Directors; and/or its employees, agents, lessors or volunteers. I understand that volunteer facilitators are asked to complete a series of written evaluations that assess their views on the DDD program after the program. I understand that I, alone or with other participants and/or sponsor staff, volunteers, or representatives, may be photographed, recorded on film, audio tape, videocassette, or other visual and sound, computerized, telephonic, voice-mail or tape media (“photographs and/or sound/image recordings”) by the sponsor and/or others approved by sponsor. I understand that volunteers must maintain appropriate conduct and follow clear guidelines with all minors participating in DDD. Appropriate conduct and guidelines are outlined on the "Facilitator Code of Ethics: Professional Boundaries When Working with Minors" sheet. I certify that the information provided in this application is true and complete. I authorize the sponsor to investigate the facts presented in this application and to secure any necessary information from all employers, references, academic institutions, and other organizations. I also agree to execute any additional written authorizations necessary for sponsors to obtain access to and copies of records pertaining to this information. I agree to release any person, company, or other institution from any and all cause of action that otherwise might arise from supplying sponsors with information it may request pursuant to this release. I understand that acceptance of my offer of volunteer services to the sponsor is contingent upon receipt of satisfactory responses to any or all investigations conducted by the sponsor. I understand that any false answers or statements, or misrepresentations by omission, made by me on this application or any related document, will be sufficient for rejection of my application, or for my immediate discharge if discovered after I begin providing volunteer services. I agree to comply with all applicable policies, procedures and rules of the sponsor, and I understand that any violation may result in my immediate dismissal as a volunteer. I understand that nothing in this application, or in acceptance of my offer of volunteer services, is intended to create an employment contract between the sponsor and me. I hereby acknowledge that I have read and understand the preceding statement *Print NameSignature *Sign on the line with mouse cursor or with your finger on a touchscreen.Reset SignatureSignature is required.Date *Submit