Application
ProActive Caring
Mindfulness Strategies & Meditations
Train the Trainer Series

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* 1. Contact Information:

Name

Company

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 2. Mobile Phone Number

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* 3. Work Phone Number

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* 4. Please indicate which is your preferred phone number - home, work or mobile.

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* 5. County

About You:

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* 6. I am a: (Select all that apply.)

Parent/Family Member

Professional/Community Member

Person with a Disability/Self-Advocate

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* 7. Gender:

Male

Female

Other

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* 8. The area where I live is:

Urban

Suburban

Rural

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* 9. My ethnicity is:

Hispanic or Latino

Not Hispanic or Latino

Undisclosed

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* 10. My race is:

White or Caucasian

Black or African American

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Two or more races

Undisclosed

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* 11. I serve in a leadership or advocacy position regarding disabilities (coalition, policy board, advisory board)

Yes

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* 12. My knowledge of the use of mindfulness strategies and meditations with individuals with IDD is

Limited

Needs Improvement

Very Good

Excellent

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* 13. My confidence in using mindfulness strategies and meditations with individuals with IDD is

Limited

Needs Improvement

Very Good

Excellent

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* 14. I use mindfulness strategies and/or meditations

Everyday

Several times a week

Once in awhile

Never

Registration for Class:

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* 15. There are two (2) sessions per series with a daytime and evening option. Please select one series below:

I would like to participate in the daytime series: Day 1 - Mindful Content Training with Peggy Pisano & Lisa Nathan: Tuesday, Sept. 13, 9:00 a.m.-11:30 a.m.; Day 2 - My Guide Mobile App Training with Kevin Winslow: Tuesday, Sept. 20, 9:00 a.m. – 10:30 a.m.

I would like to participate in the evening series Day 1 - Mindful Content Training with Mindy Scirri and Theresa Drum: Wednesday, Sept. 21, 6:00 p.m. – 8:30 p.m.; Day 2 - My Guide Mobile App Training with Kevin Winslow: Wednesday, Sept. 28, 6:00 p.m. – 7:30 p.m.

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* 16. Please confirm your commitment to complete the goals of the Mindfulness Strategies and Meditations Train the Trainer Series checking the box next to each expectation.

I agree to complete the post training evaluation of the 2 trainings I choose to attend.

I agree to use at least one strategy and meditation with at least one (1) individuals with Intellectual or Developmental Disabilities (IDD).

I agree to submit post surveys through a Survey Monkey link to document use of the mindfulness strategies with individuals with IDD. (You will be asked to provide only the first name(s) of the individual(s) with whom you work.)

If you have questions or other feedback, please contact:

Valerie Capalbo, LCSW
Project Administrator
845-661-3859
vcapalbo.proactivecaring@gmail.com