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First Name *
Last Name *

Email *

Phone 1 *

Ethnic/Cultural Identity *

Denomination and Name of Church *

Clergy or Lay Person *

Occupation *

Describe your interest in becoming a trained SC2ER Facilitator.

Describe your interest. *

How long have you been involved in racial justice issues?

How long have you been involved? *

Describe your experiences within the racial justice movement.

Describe your experiences. *

Describe your contributions to enacting changes in our nation regarding racial justice, equity and inclusion.

Describe your contributions. *

Is your community or church involved with the racial justice movement?

Is your community/church involved? *

Are you currently involved with other organizations or groups involved in addressing systemic racism?

Are you involved with other groups? *

What kind of political and social advocacy and activism are you currently engaged in?

Political, social advocacy, and activism. *

What books have you read or studied on the topic of the history of systemic racism and diverse cultures?

Book titles *

SC2ER facilitator training requires a commitment of completing all reading and viewing assignments prior to each bi-monthly session. Are you in agreement with completing all of the required assignments for the year-long study?

SC2ER Commitment *

Please provide 2 references, names, email, affiliation, and phone number.

SC2ER Reference 1 *

SC2ER Reference 2 *

Provide additional information you consider valuable in evaluating your preparedness for SC2ER facilitator training.

Additional information *