Co-operative Education and Development (CEAD) FALL 2023 Online Introduction Workshops—Application

Name

Street Address

City

Zip

Phone Number

Birth Date:

Last 4 Digits of SS#:

Ethnic Identity:

Gender Identity:

Parole or Probation # (if it applies):

Are you impacted by Incarceration? Check Those that Apply?

Have you been incarcerated? Do You have a loved one who has been incarcerated? Do you have a loved one who is currently incarcerated? Have you been arrested, detained, or harassed by the police?

Do you have access to the internet? Please check those that apply?

Phone Ipad Computer

Have you taken the Introduction Workshops in the past?

Yes No

We provide a $25 stipend for those who are taking the workshop for the first time, not working or underemployed, and from systems impacted communities. Do you request a stipend?

Yes No

Are You available to attend all workshops?

Yes No

Do you have any ideas for Cooperative Business that you want to explore further?

Are you interested in Collective REMAKE’s Train-the-Trainers Program so be come a future Co-op educator and facilitator?

Yes No

Do you have any questions? Is there something you want to share about yourself? Do you have specific needs or obstacles that will effect your efforts to take the workshops?

Co-operative Education and Development (CEAD) FALL 2023 Online Introduction Workshops—Application

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