Thank you for your interest in being trained to become a certified My Life My Choice Exploitation 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. Any questions should be directed to Niah Tobarri, Prevention and Training Coordinator, at ntobarri@jri.org.   

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* 1. Personal Information

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* 2. Employer Information

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* 3. What type of organization is this?

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* 4. Are you a licensed social worker interested in earning CEUs for this training?

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* 5. Please check all that apply to your experience and provide details below.

**If you identify as a survivor of commercial sexual exploitation or trafficking, you are eligible for a scholarship that covers part or all of the training costs (not including travel expenses). Please email Niah Tobarri at ntobarri@jri.org if you are interested.
You are also invited to attend a survivor networking breakfast from 2-3pm on Day 1 of the training.

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* 6. The age and gender identity of my clients are:

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* 7. Please describe your experience facilitating groups for youth:

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* 8. 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 Kyle Mushkin, Director of Prevention, at kmushkin@jri.org.

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* 9. Are you bilingual/multilingual?

Prior training on Commercial Sexual Exploitation of Children (CSEC) is a pre-requisite to attend the My Life My Choice Prevention Curriculum Training.

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* 10. Have you participated in the full day My Life My Choice training on Understanding and Responding to Victims of Commercial Sexual Exploitation?

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* 11. 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?

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 Niah Tobarri (ntobarri@jri.org) for more information.
My Life My Choice Exploitation Prevention Groups are designed to be facilitated at the organization where you are employed when you are trained, or at a partner agency that has contracted with you to provide the group as an employee of that organization (i.e. if you work at a child welfare organization, and will co-facilitate the group at a community-based agency).

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* 12. If you will facilitate Exploitation Prevention Groups at a partner agency, rather than where you are employed, please provide the name of that organization:

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* 13. Which type of organization is this?

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* 14. Are you employed by a faith-based organization?

Please note that My Life My Choice is a secular curriculum. If you have questions concerning this, please contact Kyle Mushkin at kmushkin@jri.org.
The My Life My Choice Prevention model requires that each group is run by two Certified Facilitators. Best practice is co-facilitation by a survivor of CSEC and someone with clinical training and experience.  Facilitators may work at the same organization, or may collaborate with other Certified Facilitators at a local partner organization(s).

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* 15. Will you personally co-facilitate My Life My Choice Prevention Groups at your site/agency or a partner organization?

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* 16. Do you plan to send two people from your agency to this training?

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* 17. A CSEC policy for your site/agency, which includes mandated reporting policies as well as procedures for handling disclosed or suspected exploitation, must be in place in order to facilitate a My Life My Choice Prevention Group. Please attach here:

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* 18. 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?

Please note, your agency is not eligible to hold a prevention group until a CSEC policy is in place.

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* 19. Do you have a plan in place for appropriate referrals to support a youth who discloses CSEC? (Please include this information in your CSEC policy).

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* 20. Do you have a relationship with local law enforcement in order to support a youth who discloses CSEC?

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* 21. If you are a 24 hour program, do you have staff on each shift who have been trained in responding to disclosures involving the Commercial Sexual Exploitation of Children?

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* 22. Is your agency administrator aware and in support of the use of the Curriculum in your program?

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* 23. Please enter your agency administrator's contact information

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* 24. Please attach your resume here:

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* 28. Would you like to receive the Curriculum (and facilitate groups) in English or Spanish?

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* 29. How did you hear about the My Life My Choice Prevention Curriculum Training?

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* 30. The live remote training sessions will be recorded for the use of participants and ongoing quality improvement for instructors. Do you consent to being recorded for these reasons?

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* 31. Please provide the mailing address where you would like to receive a copy of the My Life My Choice Prevention Curriculum book.

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* 32. How did you hear about us?

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* 33. Do you have any other questions?

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