Common Bond Institute

7th Annual International Conference on
"ENGAGING THE OTHER:" The Power of Compassion

May 4-5, 2013 ~  Dearborn, Michigan USA

Common Bond Institute ~ People's Peace Fund ~ Michigan State University ~ International Humanistic Psychology Assoc.
Dialogue Facilitator Form*
(PLEASE TYPE OR PRINT CLEARLY, AND SUBMIT IN PLAIN TEXT FORMAT TO ALLOW FOR EASY EDITING)
* See Posted Guidelines for Dialogue Groups on our website

1. Name & Credentials ____________________________________________

    Address _______________________________________________________

                  _______________________________________________________

    Phone day (    )                                 eve (    )                             Fax (    )                    

    E-Mail:                                                 Web:                                                               

2. Facilitator Style and Methods: Please describe your facilitation style and give examples of any particular tools or methods you utilize (use additional page in needed):

 

3. Description of Dialogue Groups: These are concurrent groups all participants take part in, 60-90 min. in length, occur once or twice a day for a total number of 3 or 4 dialogue group periods in the full schedule. Either individual facilitators or teams of 2 facilitators are possible. Individuals can also be paired up in advance as wished. (*Please read full description of Dialogue groups and guidelines on our website at: www.cbiworld.org/Pages/Conferences_ETO_ProgOverview.htm)

4. How many sessions are you available for and what days? ___________________

5. Personal/Professional Biographical Statement (for printed program - max. 75 words). Please include credentials/degrees, occupation, any position, and a current brief resume.
Co-facilitators: If you have a co-facilitator please also include their name and information.

 

 

6. PLEASE NOTE: The ETO Conference is a Dialogue Process meant to build as a learning community over the 2 days of the program toward strategies and collaboration. As a result we strongly encourage facilitators and presenters to be with us for all or most of the conference. Will you be participating throughout the conference? ______

7. If you are a licensed practitioner, has your professional license or insurance ever been on probation, suspended, or revoked?   [ ] Yes  [ ] No   If yes, please explain on a separate sheet.

8. 2 Professional References (names, position, relationship, & contact info., including e-mails):

Submission

Please submit forms by E-mail (preferred), fax, or land mail to:

   Common Bond Institute
Details at Website: www.cbiworld.org/Pages/Conferences_ETO.htm
Attn: Steve Olweean, Director, Conference Coordinator
12170 S. Pine Ayr Drive, Climax, MI 49034 USA  
Ph/Fax: 269-665-9393   Email: SOlweean@aol.com   Website: www.cbiworld.org
(This form can be copied & pasted into an Email to complete & submit)
* See Posted Guidelines for Dialogue on our website at:
www.cbiworld.org/Pages/Conferences_ETO_ProgOverview.htm

(Dialogue Group Facilitators receive a 25% discount off program fee)