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* 1. First Name

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* 2. Last Name

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* 3. Name of Organization

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* 4. Job Title

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* 5. Can you commit to the following training dates?  Describe any scheduling conflicts.  
Dates: 9am-3pm, each day.
October 8th, 2019
November 12th, 2019
December 3rd, 2019
January 14th, 2019
April 7th, 2019
May 12th, 2019

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* 6. We will alternate training sites between Chittenden and Washington Counties.  Do you have reliable transporation to attend training at various sites?

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* 7. Why would you like to attend the Leadership Institute in Restorative Practices in Afterschool?  

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* 8. How do you hope this experience will affect your work in afterschool?

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* 9. Do you need any special accommodations in order to fully participate, or have any dietary needs?  

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