Date I attended the SEMINAR: FOUNDATIONS OF RACIALLY CONSCIOUS COLLABORATION™ with Tony Hudson. *This is a pre-requisite to start Collaborator™ _____________ *October 1 Registration will be available late summer (we will send an email with the link to register to those that complete this interest form). _____________ *

Name *

My race and gender are... *

The organization/workplace I would like to collaborate in... *

List your supervisor or organizational contact name and email where we may follow up for certification fee and contractual commitment. If self list "SELF". *

Cell phone number (include area code) *

I accept text messages *

Cohort I'd like to participate in (check all that apply)

Visit https://bit.ly/2QEfSwh. Check below if you agree to attend the required dates in bold.

I learned about Tony Hudson and Racially Conscious Collaboration™ by....

I am interested in certifying as a Collaborator™ because...

How would you apply a tool for more effective cross racial dialogue at the PERSONAL level?

How would you apply a tool for more effective cross racial dialogue at the PROFESSIONAL level?

Q1: I would describe my racial consciousness as...

Q2: Race impacts my personal and professional relationships and collaboration by...

Q3: I want to increase my capacity for racially conscious collaboration because...

Video submission. Record a brief introduction to our RCC team for the 3 questions listed above. Use your phone or computer to email us a file that is less than 20MB or send us a youtube link (or link to where we can watch your video). Be sure to mark the video settings as "unlisted" and not "private" so we can view it with your link. Check the audio and visual clarity before you submit your video to us. Videos should not be longer than 5 minutes in length. For tips visit: youtu.be/nvL-mtBZKQs

(2) Emails of support - Ask 1 personal contact or colleague and 1 supervisor or mentor to send a brief email of support for you as they speak to how/why you would lead others to talk about race. They may email their support for you to Collaborator@RaciallyConsciousCollaboration.com

1 - Personal or Colleague (list name and email of the person who tell us more about you)

2 - Supervisor or Mentor that you have worked with in the past 5 years (list name and email of the person who will tell us more about you)