Facilitator Training & Certification Application

Please read through the web page entitled, “Becoming a Certified Facilitator of The Samurai Game®,” before completing this application. Also, please note that applicants must have participated in at least one Samurai Game® prior to acceptance in the Facilitator Training and Certification program.

Step 1 of 3

Contact Information
First Name*
Last Name*
Your Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Preferred Phone Number*
Other Phone Number
Email*
Website
Tell us about your work...
Your Occupation*
Company Name
Company Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
What is your position with this company?
Years with the company?
What does the company do?

Tell us about your experience and interest in The Samurai Game®...
How many times have you played The Samurai Game®?*
*Please note that you must have participated in at least one The Samurai Game® in order to enter the Facilitator Training & Certification Program.
Please list the Date, Facilitator's name and Location of each Samurai Game® you've attended:*
For what purpose do you desire to be trained and certified to facilitate The Samurai Game®?*
At this point, whom do you expect to serve when you are a Facilitator of The Samurai Game®?*
If certified, approximately how frequently would you anticipate facilitating The Samurai Game®?*
Tell us about your personal or professional experience that may be relevant to your successful facilitation of The Samurai Game®...
Describe your experience facilitating group processes and/or experiential education:*
Other thoughts you'd like to share with us?
Please provide names, email and phone numbers of three professional references:
#1*
Name Email Phone
#2*
Name Email Phone
#3*
Name Email Phone

Which Facilitator Training & Certification (FTC) program are you interested in?
Dates for the next Facilitator Training and Certification program to be determined
- First Choice
Additional Information
Please upload your current resume or a simple biographical statement:*
Drop files here or

Max. file size: 256 MB.
Maximum file size: 250 MB
Please upload a current photo of yourself (headshot)*
Max. file size: 256 MB.
Maximum filesize: 250 MB
Please click “Submit” below. We will review your application and get back to you within 3 business days. Once your application has been accepted, you will recieve an invoice and payment instructions to reserve your space in an upcoming Facilitator Training & Certification program. Thank you for your interest in becoming a certified Facilitator of The Samurai Game®!

Facilitator Training & Certification Application

Facilitator Training & Certification Application

Step 1 of 3

Contact Information

Tell us about your work...

Tell us about your experience and interest in The Samurai Game®...

Tell us about your personal or professional experience that may be relevant to your successful facilitation of The Samurai Game®...

Please provide names, email and phone numbers of three professional references:

Which Facilitator Training & Certification (FTC) program are you interested in?

Additional Information

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