June 2023 - Foundational Mediation Training

Personal Information

• * First Name:
• * Last Name:
• * Email Address:
• * Confirm Email Address:
• * Address 1:
• * City:
• * State: --Choose-- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming -------------- Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory
• * ZIP Code:
• * Phone:
• * Cell Phone:
• Occupation:
• Employer

• Fee

  Type	Fee
  Event fee	$695.00
  Event fee type 2	No Charge

• Preferred Name:

• What pronouns would you like us to use to refer to you during the training?

  • She/Her
  • He/Him
  • They/Them
  • Other (please write in below)
• If you selected "Other", please write your pronouns here:

Demographic Information (Optional - used for city and state reporting)

• Age

  • 18-24
  • 25-44
  • 45-54
  • 55-61
  • 62 and Over

• Race (select as many as apply)

  • American Indian/Alaska Native
  • Asian
  • Black/African American
  • Native Hawaiian/Pacific Islander
  • White

• Do you identify as Latino or Hispanic?

  • Yes
  • No

• Income Level (Annual)

  • <$12,083
  • $12,083-$19,635
  • $19,636-$32,725
  • $32,726-$52,360
  • >$52,360

• Do you identify as a person with a disability?

  • Yes
  • No
• What languages do you speak fluently?

• Gender (select as many as apply):

  • Woman
  • Man
  • Non-Binary
• Is there anything else you would like us to know about your gender?

To help us better serve you at the training, please answer the questions below.

• * How did you hear about this training?
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• * Have you had any previous training that you think is relevant?
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• * What do you hope to gain from this training?
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• What led you to this training? Is there a connection with the work you do now?
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• Is there anything else you'd like us to know about you?
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• Access Needs (note: all training spaces are wheelchair accessible, involve fluorescent lighting, and are not scent-free at this time)
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• *

  Cancellation Policy: If you cancel 28 days (4 weeks) or more before the training, your fee will be refunded, minus a $25 processing fee. If you cancel 14- 27 days before training, 50% of your fee will be refunded. If you cancel within 2 weeks (1-13 days), there is no refund; however, you can transfer your spot to someone else. If you cancel once the training begins, there is no refund or credit voucher. Exceptions may be made in case of emergencies, please contact us for more info.

  • Agree
• *

  Attendance Policy: This training features active in-class participation. Attendees are expected to attend and participate all parts of the training and to notify info@seedscrc.org in advance of anticipated absence. At this training, you may only make-up up to 3 hours of missed time for credit. Your certificate will reflect the number of hours completed.

  • .Agree
• *

  Content disclaimer: This introductory training of mediation features content and discussion regarding race, power dynamics, and privilege in society. Folx attending this training including trainers come from various lived experiences and understandings. BIPOC and other marginalized folx do not have to carry the additional burden of educating anyone while attending. Please know that you have autonomy to engage and care for yourself as you need for your own wellbeing.

  • I understand.