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Survivor Apprenticeship Program
Name
*
First Name
Last Name
Email
Date of Birth
*
MM
DD
YYYY
Phone number
*
(###)
###
####
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Emergency Contact
*
First Name
Last Name
Race
What is your highest level of education?
Do you currently have stable housing? (such as a long term residential program or in your own apartment/home)
(Not currently living in a short term shelter, in a motel, car or homeless)
Yes
No
Do you have reliable internet and a space where you can participate in live discussions and complete assignment?
*
Yes
No
Have you been out of trafficking and/or exploitation for over 12 months?
Yes
No
Do you have a history of sexual abuse?
Yes
No
Have you experienced domestic violence?
Yes
No
Do you have a history of substance abuse?
Yes
No
If you have a history of substance abuse, have you been in recovery for over 12 months?
Yes
No
What type of trafficking or exploitation have you experienced?
Select all that apply.
Sex Trafficking
Labor Related Trafficking
Commercial Sexual Exploitation
Pimp Controlled Trafficking
Gang Related Trafficking
Familial Trafficking
Illicit Massage Business
Drug Related Trafficking
Survival Related Exploitation
Child Sex Trafficking
Pornography
Strip Club
Escort Service
Street/Track/Outdoor Solicitation
Online (online services/ads)
Domestic Servitude
Agriculture/Farm
Hotel/Hospitality/Food Service
Factory/Manufacturing
Construction
Landscaping
Do you have a strong support system? (such as a peer support group, therapist, church/faith based support and/or family support)
We would love to hear about your support system.
Are there are supports that you may need while working through this program?
Which course are you most excited about?
Professional Development
Human Trafficking Law and Typology
Healing Centered/Trauma Informed Approaches
Digital Literacy
Business Structures
Public Speaking
Thank you!
