Train the Trainer Application Form GENERAL INFORMATION Title * Ms.MissMrs.Mr.Other TitleName Name First First Last Last Preferred Name Pronouns They/Them/TheirsShe/Her/HersHe/Him/His Email Mobile Number Street Address Include number and street name, Apt/Unit # City State Zip Code Date of Birth * Race/Ethnicity National Origin Languages Spoken English Spanish French Swahili Farsi Chinese Korean OtherOther Year ICTC/SMC Certified Please enter 4-digit yearHave you ever been convicted of a Felony? * No Yes Name of Emergency Contact * Please include First and Last Name of the Contact Relationship to Contact * Emergency Contact Email * Emergency Contact Phone # * ONLINE PRESENCE Website/URL Facebook Name Instagram Name Twitter/X Name LinkedIn Name PROFESSIONAL INFORMATION Profession * Employer Name * Business Address * REFERENCES Reference #1 First and Last Name Profession Contact Number Email Reference #2 First and Last Name Profession Contact Number Email Reference #3 First and Last Name Profession Contact Number Email Reference #4 First and Last Name Profession Contact Number Email Reference #5 First and Last Name Profession Contact Number Email DOCUMENTS SMC Doula Certification Drop a file here or click to upload Choose FileMaximum file size: 268.44MB Resume/Curriculum Vitae Drop a file here or click to upload Choose FileMaximum file size: 268.44MB Passport Photo or Headshot * Drop a file here or click to upload Choose FileMaximum file size: 268.44MB Other Qualifications Drop a file here or click to upload Choose FileMaximum file size: 268.44MB Background Check Results Drop a file here or click to upload Choose FileMaximum file size: 268.44MB Proof of Volunteer Experience Drop a file here or click to upload Choose FileMaximum file size: 268.44MB Proof of Teaching 48 hours of Childbirth Education Drop a file here or click to upload Choose FileMaximum file size: 268.44MB Proof of Teaching 48 hours of Breastfeeding Education Drop a file here or click to upload Choose FileMaximum file size: 268.44MBDECLARATIONI, the undersigned applicant, declare that the information in this application form is true and accurate, and I have not willfully suppressed any material fact. Signature signature keyboard Clear Date GUIDANCE NOTES FOR APPLICANTSThese notes are intended to help you complete the Application. You should read them carefully as the decision to short-list for an interview is based solely on information provided in the application. • Missing information or incomplete application will result in the application being rejected. • When completing your application, please ensure that you give priority to education and qualifications that are relevant to the program. • Details of qualifications should be included in your CV. • Please ensure to sign the Application Form. • Envelopes should be marked with the Expression of Interest reference. • You scan the application and email it. • Giving false information in your Application Form will render your application invalid, or, if enrolled, may lead to withdrawal from the program. Relevant original certificates/testimonials should be produced upon request. Submit If you are human, leave this field blank. Share this: Share on Facebook (Opens in new window) Facebook Share on X (Opens in new window) X
