SILMM Registration Form

Welcome to the Social Impact Leaders Mentoring Marathon

Thank you for taking the time to complete this form and be part of the SILMM specially designed for you by Safiya Ibn Garba DTRF. We will keep your information confidential and it will only be accessed on a need to know basis. This form will take five minutes to complete. Please get in touch with us if you have any questions.

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* 1. Full Name (as you would like it to appear on the certificate)

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* 2. Gender Identity

Female

Male

Other

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* 3. Age Range

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* 4. Please describe any difficulty you experience participating in everyday life.

Difficulty seeing, even when using glasses

Difficulty hearing, even when using a hearing aid

Difficulty walking or climbing stairs

Difficulty remembering or concentrating

Difficulty with self-care, such as with bathing or dressing

Difficulty using my usual language, difficulty in communicating (for example, understanding others or being understood by others)

No difficulty

Other (please specify)

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* 5. Email:

Email address

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* 6. In what country do you live?

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* 7. Which of the below best describes your preferred learning style?

Visual (I like diagrams, pictures, video, slides, colors, symbols, highlighting etc.)

Auditory (I like to discuss, explain ideas out loud, tape record, listen to podcasts, remember stories/examples, study aloud with a partner etc.)

Read and Write (I like lists, handouts, notetaking, manuals, workbooks etc.)

Kinesthetic: (I like Likes field trips, labs, real-life examples, trial and error, problem - solving)

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* 8. Please rate on which theme you would like more mentoring (where 1 is the least time required and 5 is the most time required).

	1	2	3	4	5
Transformational Leadership	Transformational Leadership 1	Transformational Leadership 2	Transformational Leadership 3	Transformational Leadership 4	Transformational Leadership 5
Governance and Sustainability	Governance and Sustainability 1	Governance and Sustainability 2	Governance and Sustainability 3	Governance and Sustainability 4	Governance and Sustainability 5
Resource Mobilisation and Management	Resource Mobilisation and Management 1	Resource Mobilisation and Management 2	Resource Mobilisation and Management 3	Resource Mobilisation and Management 4	Resource Mobilisation and Management 5
Impact and Results Driven Management	Impact and Results Driven Management 1	Impact and Results Driven Management 2	Impact and Results Driven Management 3	Impact and Results Driven Management 4	Impact and Results Driven Management 5
Self Care and Wellbeing	Self Care and Wellbeing 1	Self Care and Wellbeing 2	Self Care and Wellbeing 3	Self Care and Wellbeing 4	Self Care and Wellbeing 5

SILMM Registration Form

Welcome to the Social Impact Leaders Mentoring Marathon

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* 1. Full Name (as you would like it to appear on the certificate)

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* 2. Gender Identity

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* 3. Age Range

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* 4. Please describe any difficulty you experience participating in everyday life.

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* 5. Email:

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* 6. In what country do you live?

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* 7. Which of the below best describes your preferred learning style?

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* 8. Please rate on which theme you would like more mentoring (where 1 is the least time required and 5 is the most time required).

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* 9. Share in one word how you would describe where you are in your social impact journey.

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* 10. What is your expectation of this mentoring marathon?

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* 11. Please add your payment transaction name and number.