Thank you for your interest in being trained to become a certified My Life My Choice Prevention Curriculum group facilitator. Completing this application is the first step in the certification process. You will be notified of your application status within three business days of submission. Applications and any questions should be directed to the Director of Prevention, Amy Corbett at acorbett@jri.org. Question Title * Personal Information Name * Address * Address 2 City/Town * State/Province * -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code * Email Address * Question Title * Employer Information Agency Job Title Question Title * Are you interested in Social Work CEU's? Yes No If yes, please enter license number Question Title * Are you a Massachusetts DCF worker or Caring Together Provider? Yes No If yes, are you interested in a scholarship to attend this training? Question Title * Please check all that apply to your experience and provide details below. Master's Level Clinician Survivor of commercial sexual exploitation At least 5 years of clinically related experience, specifically working with victims of trauma Experience working with survivors of commercial sexual exploitation or human trafficking Experience working with at-risk youth Please elaborate years of experience and provide additional details that you feel makes you an appropriate candidate to participate in this facilitator training, including experience facilitating groups for youth: Question Title * I identify my gender as: My Life My Choice believes that it is best practice for people who identify as female to facilitate these groups. If you identify as male and are interested in facilitating a group, please contact Amy Corbett (acorbett@jri.org). Question Title * Are you bilingual/multilingual? Yes No If yes, what languages do you speak? Prior training on Commercial Sexual Exploitation is a pre-requisite to attend the My Life My Choice Prevention Curriculum Training. Question Title * Have you participated in the full day My Life My Choice training on Understanding and Responding to Victims of Commercial Sexual Exploitation? Yes No If yes, please provide the date you attended the training. Question Title * If you answered "no" to the previous question, have you had prior training on the Commercial Sexual Exploitation of Children (CSEC) in the past year? Yes No Not Applicable, as I have had training by My Life My Choice in the past year (see above). I am registered to attend a My Life My Choice (please enter date below). If yes, please note the title of the training, the date you were trained and the agency that provided the training, including format of training (webinar, full day, half day, etc.). If you have not attended a training on CSEC, you will need to attend this training prior to registering for the My Life My Choice Prevention Curriculum Training. Please contact Amy Corbett-acorbett@jri.org for more information. The My Life My Choice group/curriculum is designed to be facilitated at the site/agency where you are employed when you are trained. Question Title * Please tell us about the site where you are employed and intend to facilitate the My Life My Choice Prevention Curriculum. Community Based Ageny Court/Probation School Juvenile Justice Facility Group Home/Residential Program Runaway/Homeless Youth Shelter I am not connected to a site/agency Other (please specify) Question Title * Are you a faith-based organization? Yes No Other (please specify) Please note that My Life My Choice is a secular curriculum. If you have questions concerning this, please contact Amy Corbett at acorbett@jri.org The My Life My Choice Prevention model requires that groups are co-facilitated: best practice is by a survivor of CSEC and an experienced clinician. Question Title * Do you plan to facilitate a My Life My Choice Prevention Group at your site/agency? Yes No If you do not plan to facilitate groups, please describe your interest in this training Question Title * Do you plan to send two people from your agency to this training? Yes No If no, please explain your plan for facilitating groups Question Title * A CSEC Policy for your site/agency, that includes mandated reporting (if applicable to your State), for handling disclosed or suspected exploitation, must be in place in order to facilitate a My Life My Chioce Prevention Group. Please attach here: DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only. Choose File Choose File No file chosen Remove File A CSEC Policy for your site/agency, that includes mandated reporting (if applicable to your State), for handling disclosed or suspected exploitation, must be in place in order to facilitate a My Life My Chioce Prevention Group. Please attach here: Question Title * If you do not have a CSEC policy in place, are you committed to developing a policy and submitting it to My Life My Choice within 3 months? Yes No Please note, you are not eligible to facilitate a prevention group until a CSEC policy is in place. Question Title * Do you have a plan in place for appropriate referrals to support a youth who discloses CSEC? (Please include this info in your CSEC policy). Yes No Question Title * Do you have a relationship with local law enforcement in order to support a youth who discloses CSEC? Yes No Question Title * If you are a 24 hour program, do you have staff on each shift who have been trained in responding to disclosures around the Commercial Sexual Exploitation of Children? Yes No Not Applicable, as I am not at a 24 hour program. Question Title * Is your agency administrator aware and in support of the use of the curriculum in your program? Yes No Question Title * Please attach your resume here: DOCX, DOC, JPG, GIF, JPEG, PDF, PNG file types only. Choose File Choose File No file chosen Remove File Please attach your resume here: Question Title * I understand that by participating in this facilitator training, I will be required to sign and complete the My Life My Choice Licensing Agreement. (Once approved, you will receive a copy of this agreement to be signed). I agree I do not agree Question Title * I understand that my agency will be required to submit a CSEC agency policy within 3 months of facilitator training and or/prior to initiating groups, if one is not already in place. CSEC policy is attached above I agree I do not agree Question Title * I understand that to become certified as a My Life My Choice Prevention Curriculum facilitator, I must have prior training on the Commercial Sexual Exploitation of Children, either through My Life My Choice or another agency that qualifies. I agree I do not agree Question Title * Do you have any other questions? 100% of survey complete. Submit
