ETC Parent Trainer Application (Train-the-Trainer) This application needs to be filled out by each parent. Step 1 of 5 – General Information 20% Name* First Last Birthdate* MM DD YYYY Gender*MaleFemaleRace/Ethnicity*White or European AmericanBlack or African AmericanHispanicAsianNative American or Alaska NativeNative Hawaiian or other Pacific IslanderMiddle Eastern or North AfricanEmail* Cell Phone*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican 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 RicoQatarRéunionRomaniaRussiaRwandaSaint 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 IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Save and Continue Later Employment InformationPlace of EmploymentJob TitleEmployment Statusn/aContractPart TimeFull TimeHighest Level of Education*Some high school, no diplomaHigh school graduate, diploma or the equivalent (for example: GED)Some college credit, no degreeTrade/technical/vocational trainingAssociate degreeBachelor’s degreeMaster’s degreeProfessional degreeDoctorate degreeOnline/Social MediaPersonal Website/Blog Personal Twitter Account (username)Personal Facebook Account Personal Instagram Account (username) Save and Continue Later Family InformationReligionName of Place of WorshipLocation of Worship PlaceChildrenYear of First Adoptive/Foster Placement*Names of Children*How did the children enter your family?*Example: Birth, Adoption, Foster Care, Kinship, etcFor each child (not including any current foster children), please indicate his/her age and briefly describe any special needs (medical, physical, emotional, etc.) and/or behavioral challenges that you are currently aware of.*Do you currently have plans to adopt again? If yes, please describe your current plans and explain how adopting again might impact your ability to train other families and serve in adoption/foster care ministry.*Are you currently 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 in adoption/foster care ministry.*Have you ever dissolved an adoption?*YesNoPlease share the circumstances that led you to this decision.*Have you ever disrupted an adoptive or foster placement?*YesNoPlease share the circumstances that led you to this decision.*What are the most significant challenges that you have faced thus far as an adoptive/foster parent?Are you a transracial family? If so, please describe what you have learned through that experience?Describe your relationship/relationships or lack thereof with your adoptive or foster children's biological families.How do you view your role as an adoptive or foster parent? In other words, please complete this thought: My role as a parent is to…Describe the parenting tools that you use most often.*What books or resources do you rely on most in your parenting? (List your top 5)When did you first become familiar with Trust Based Relational Intervention (TBRI) and the connected parenting strategies developed by the Karyn Purvis Institute of Child Development?*In which of the following ways have you previously engaged the connected parenting material? I have read The Connected Child I have watched DVDs produced by the Karyn Purvis Institute of Child Development I have worked through the Created to Connect Study Guide 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 have hosted the Empowered to Connect Conference Simulcast I have completed the Empowered to Connect 9 week Connect Course I have completed the Empowered to Connect 6 week Prepare Course Connect Course: when, where, and who were your trainers?*Prepare Course: when, where, and who were your trainers?*List and briefly describe the most significant insights you have gained from Dr. Purvis’ work.*What do you believe is the role of the local church in terms of adoption and foster care?* Save and Continue Later Ministry/Nonprofit NameMinistry/Nonprofit Website Ministry/Nonprofit Facebook Account Ministry/Nonprofit Twitter Account Describe the adoption/foster care ministry or nonprofit that you are involved in. Be sure to include how long it has been in existence, its main areas of focus, and what types of activities, events, and trainings it offers.Describe your involvement and/or role(s) in the ministry/nonprofit?Why are you involved in this ministry/nonprofit?What are the greatest needs of the parents/families you serve (or seek to serve)?Describe a situation or experience involving another family that you have served/supported that best captures how you supported them.Have you used the teachings of the Karyn Purvis Institute of Child Development in your ministry? If so, please describe. Save and Continue Later What is your primary motivation for wanting to become an Empowered to Connect Parent Trainer and how do you plan to implement the ETC parent training in your community?ReferencesPlease list the names and emails of 3 references:Reference #1 Name*Reference #1 Email* Reference #2 Name*Reference #2 Email* Reference #3 Name*Reference #3 Email* Consent*During this event, Empowered to Connect may choose to photograph, video, and audio record. By applying to become an Empowered to Connect Trainer you consent to be photographed, video, and audio recorded you hereby grant ETC permission to use such photographs and recordings for commercial or any other purposes without compensation and waive any and all rights of privacy or publication related thereto and release ETC from any claim or liability for loss, damage, or compensation from the commercial or other use of your name, likeness, image or voice. I have read and understand the photo/video/audio consent statement.PhoneThis field is for validation purposes and should be left unchanged. Save and Continue Later This iframe contains the logic required to handle Ajax powered Gravity Forms.