EmailMe Form - Support Group Facilitator Application

EmailMeForm

Name *
First Last
Email *
Phone *
### - ### - ####
Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
County *
Education
Employer
Job Title
Gender *
Male
Prefer not to disclose
Female
Other
What languages are you fluent in? *
English
Spanish
Creole
Other
Do you have lupus? *
Yes
No
If yes, what year were you diagnosed?
If no, what is your connection to lupus? *
I am a caregiver of someone with lupus
I know someone with lupus
I have lost someone to lupus
I do not have any connection to lupus
I am a healthcare provider
Which LFAFL events and/or programs have you attended in the past? (check all that apply)
Support Group
Walk To End Lupus Now
Seminar
Teleconference
Advocacy Event in Tallahassee
Advocacy Event in Washington, DC
I have organized a 3rd Party Fundraiser
I have never attended a LFAFL event
Other
How long have you been involved with LFAFL or any of our affilates?
Less than one year
1-5 years
More than 5 years
This would be my first time being involved with LFAFL or it's affilates
Have you ever been affiliated with another non-profit, including another lupus organization? *
Yes
No
If yes, please name the organization and your involvement. *
How did you hear about the LFA Florida Facilitator Application/Training? *
Social Media
A LFAFL Staff Member
Email/Newsletter
LFAFL Website
Someone I know was a facilitator in the past
Why do you want to be an LFAFL Support Group Facilitator? *
Are you willing to assume the responsibility of Support Group Facilitator for at least one year? *
Yes
No
Are you willing to commit to facilitating a minimum of eight meetings per calendar year? *
Yes
No
Are you willing to work collaboratively with the LFAFL which will include being supervised, submitting group reports, etc. during the time your group is operating? *
Yes
No
LFA support groups meet at various times. What is your availability to facilitate a group? (check all that apply) *
Weekdays
Weekends
Morning
Afternoon
Evening
The LFA strongly encourages all support groups to have a co-facilitator. Are you willing to work with a co-facilitator? *
Yes
No
If you have a co-facilitator in mind at this time, please include their name and contact information below.
Please describe your background, experiences, and/or skills that will help you be an effective lupus support group facilitator - such as knowledge of group facilitation, health education, or work with people with chronic illnesses. *
Please write a brief statement describing your personal attributes and communication style that you feel will help make you successful as a support group facilitator. *
Have you ever been convicted of a felony? *
Yes
No
I have not been convicted, but I have pending charges against me
If yes or have pending charges, please explain.
By submitting this form and signing below, I certify that all statements made on this form are true, complete, and correct. *
Clear
Please use your mouse to sign (click and sign)