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To apply for a facilitator role for your community and/or Courageous Parenting 101, please submit the form below or download the form here and mail it to Courage to Speak Foundation, PO Box 1527 Norwalk, CT 06852. If you have any questions, please call 1-877-431-3295.
 

Courageous Parenting 101 Facilitator Application Form

All fields indicated with an asterisk are mandatory.

   
*Name
*Address
*City
*State
*Zip
*Home Phone
Work Phone
Cell Phone
*E-Mail
*Date of Birth
   
*Employer
Address
(of Employer)
City
State
Zip
   
*Please fill out your education background below.
School City/Town Major Year Degree
High School
College
Graduate School
Other
 

*Have you had any training or experience in serving as a group leader or facilitator?
 YES NO
If YES, please describe below.
   

*Please list other skills and experiences below:
   

*Please explain below if you are interested in serving as a facilitator for Courageous Parenting 101 and/or presenting to your parents groups.
   

*Are you associated with a school, agency, church or synagogue, or other community agency that would be interested in hosting a Courageous Parenting 101 program?
 YES NO
If YES, please fill out below.
Contact Name
Organization
Address
City
State
Zip
Phone
   

Fee for training for Courageous Parenting 101 is $375, which includes curriculum materials/facilitators guide, power point presentation and parent handouts. Complete this form electronically and mail check to The Courage to Speak Foundation, PO Box 1527, Norwalk, CT 06852.
*Will your employer or another third party be responsible for cost of your tuition
and course materials?
YES NO

I will mail a check in the amount of $

Please bill my employer/other organization in the amount of $
   

Thank you for your interest in working with parents to reduce substnce abuse and to provide parents with the tools necessary to communicate openly and honestly with their children.

If you have any questions, please contact Courage to Speak at 1-877-431-3295 or you may e-mail Ginger Katz at GKcourage@aol.com and visit our website at www.couragetospeak.org

Please return your application to:
    The Courage to Speak Foundation, Inc., PO Box 1527, Norwalk, CT  06852

   

This website is partially funded by the Connecticut Department of Mental Health and Addiction Services.
The Courage to Speak Foundation, Inc. is a nonprofit corporation. The organization has been approved by the Internal Revenue Service for tax deductible status under Section 501(c)(3). Courage to Speak is the trademark of The Courage to Speak Foundation, Inc. © Copyright 2006 Ginger Katz, Courage to Speak. All rights reserved.		  


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