This application needs to be filled out by each parent who wishes to become a Cultivate Connection Facilitator. Cultivate Connection Facilitator Application Step 1 of 5 20% Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Gender(Required) Race/Ethnicity(Required) Email(Required) Phone(Required)Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Are you currently parenting?(Required) Yes No Cultivate Connection is designed as a peer-to-peer parent course. If you are not yet parenting (biologically, adoptive, or foster), please stay connected with us through our website, our social media, and find other ways to engage with our materials and available training. Do you have any questions for the Empowered to Connect Team at this time? I am interested in participating in Facilitator Training:(Required) With my spouse/partner Individually If you are married or parenting with a partner, your partner will need to complete the online Cultivate Connection course with you, in order to ensure that all parents in the home are parenting from a similar model/framework. Spouses/Partners who have attended Cultivate Connection or ETC: Connect Course in the past 5 years are exempt from this requirement.(Required) I understand that my spouse/partner will need to attend Phase 1 (online portion) of my training in order for me to become a Facilitator I am a single parent Please briefly describe the reasons that your Spouse/Partner does not intend to Facilitate Cultivate Connection with you.(Required) Place of Employment(Required) Job Title(Required) Highest Level of Education(Required) What is your primary purpose for using social media?(Required) Personal relationships Business/Networking Marketing/Sales I do not use social media Personal Website/Blog Address Personal LinkedIn Account Personal Facebook Account (Username) Personal Twitter Account (Username) Personal Instagram Account (Username) Personal TikTok Account (Username) Please list any other Social Media Platforms Used (include usernames) Tell us about your family.(Required)Please check all that apply(Required)To meet the needs of our course participants, our Cultivate Connection Facilitators are seasoned parents with personal experience parenting children who have experienced Adverse Childhood Experiences (ACEs), or who are neurodiverse, or who were adopted, or who are in foster care. I have personal experience parenting child(ren) who have experienced trauma, stress, or adversity I have personal experience parenting child(ren) who are neurodiverse I have personal experience parenting child(ren) who were adopted I have personal experience parenting child(ren) who have been in foster care I have personal experience parenting child(ren) who have complex medical needs I do not have personal experience with this Please check all that apply(Required)Our course is a peer-to-peer parenting course that meets the needs of participants. In some circumstances, professional experience may be considered for applications who do not have personal experience parenting populations at risk for adversity. Please indicate professional experience below. I have professional experience working with child(ren) who have experienced trauma, stress, or adversity I have professional experience working with child(ren) who are neurodiverse I have professional experience working with child(ren) who were adopted I have professional experience working with child(ren) who have been in foster care I have professional experience working with child(ren) who have complex medical needs I do not have professional experience with this Please describe your experience working with populations or parenting children who are at risk for adversity.(Required)What year did you become a parent?(Required) Do you have plans to expand your family in the next year? If yes, please describe your current plans and explain how that might impact your ability to serve other families as a Cultivate Connection Facilitator.(Required)Are you an adoptive or foster parent?(Required) Yes No Are you an open foster home? If yes, please describe your current plans and explain how continuing to foster might impact your ability to train other families and serve as a Cultivate Connection Facilitator.(Required)Have you ever dissolved an adoption or disrupted a foster placement? If yes, please briefly explain the circumstances.(Required)Describe your relationship/relationships or lack thereof with your adoptive or foster children's biological families.(Required)How do you define successful parenting?(Required)What are 3-5 words that you would use to describe yourself as a parent?(Required)What are 3-5 words that you would use to describe your spouse or parenting partner as a parent (if you are parenting with a partner)?Are you a transracial or interracial family? If yes, please describe what you have learned through that experience.(Required)What are the most significant challenges that you have faced thus far as a parent? What have you learned from those experiences?(Required)What is your philosophy of discipline? How does that influence the way you discipline/correct your children? What discipline methods do you use most often?(Required)What books or resources (blogs, parent coaches, podcasts) do you rely on most in your parenting?(Required)Have any of the following models or interventions informed your parenting? Please check any that apply.(Required) Connected Parenting Gentle Parenting Peaceful Parenting Attachment Based Parenting Conscious Parenting Mindful Parenting Trauma Informed Parenting Collaborative Problem Solving Trust-Based Relational Intervention (TBRI) I am not familiar with any of these Have you engaged in any of the following ways with Empowered to Connect information, training, resources, or our Partner Organizations?(Required) I have watched Empowered to Connect videos online I have read the Empowered to Connect blog I have attended an Empowered to Connect Conference I have watched the Empowered to Connect Conference Simulcast I am a regular listener of the Empowered to Connect Podcast I have worked through the Created to Connect Study Guide I have watched videos produced by the Karyn Purvis Institute of Child Development I have attended training presented by the Karyn Purvis Institute of Child Development I have attended a Show Hope: Hope for the Journey Conference I have read The Connected Child I am not familiar with any of these List and briefly describe the most significant insights you have gained from the Models or ETC resources that you checked in the above 2 questions.(Required) Please select all that apply.(Required) I plan to facilitate courses through my specific faith community I plan to offer trainings to my community at large, including people from different backgrounds and belief systems Do you practice or participate in a religion? If yes, which one?(Required)Name & Location of Place of Worship What do you believe is the role of the local church or faith community in terms of adoption and foster care?Do you volunteer or work in any ministries/nonprofit organizations?(Required) Yes No Ministry/Nonprofit Name(Required) Ministry/Nonprofit Website Describe your role(s) in the ministry/nonprofit.(Required) How did you hear about Cultivate Connection Facilitator Training?(Required)Why do you want to become a Cultivate Connection Facilitator?(Required)What are the greatest needs of the parents/families you serve (or seek to serve)? How do you envision supporting these needs with Cultivate Connection courses?(Required)Why would you recommend yourself for the role of Cultivate Connection Facilitator?(Required)Send a Link to 2 References(Required)If you have attended an ETC:Connect or Cultivate Connection Course in the past, your first reference should be your ETC Trainer or Cultivate Connection Facilitator. If you have not, your first reference should be from a mentor/leader. Your second reference should be a personal friend who has experienced walking alongside you on your parenting journey OR a family member who has experienced walking alongside you on your parenting journey. I will receive an email link to a reference form. I understand that it is my responsibility to send the link to my 2 chosen references, and that my application is not complete until they submit the reference form online. CommentsThis field is for validation purposes and should be left unchanged. Δ
