Surrey SHARES Application Form
We want to hear YOUR story. This is an opportunity for you to work with a Life Coach and Speaking Coach to improve your well-being, learn new skills, connect with others and tell your story. Surrey SHARES is a 16-week program that will help you identify personal goals and a ‘Personally Meaningful’ story that you want to share with others. You’ll then be guided to achieve your set goals while also preparing to publicly tell your story. At the end of the program, you’ll have the opportunity to perform your story and have it recorded so that you can share it with friends, family and community.

This program is limited to 10 participants and is offered at no cost. Sessions will be conducted on-line or over the phone if we are unable to meet in person due to the need for personal distancing.

If you are interested, please apply before April 14th as selections will be made April 15-17th. The program begins on April 20th.

What you can expect from the program:
• Expert guidance from a certified Life Coach and a Speaking Coach
• A well-organized and flexible program
• Opportunity to identify your personal goals, set achievable action plans and work through any limiting beliefs that are holding you back from achieving your goals
• Opportunity to learn public speaking and how to tell great stories
• Helpful and positive feedback throughout
• Support to reach your personal and speaking goals
• Assistance with cell phone and computer technology necessary to participate

Expectations for Program Participants:
• Commit to one-hour weekly sessions with Life Coach and Speaking Coach (2 hours total)
• Complete projects between sessions
• Contribute positive feedback to other participants and Coaches
• Willingness to try new things

If you have any questions about the program, you can contact:
Jessika Houston, gngcoach@gmail.com or Noel Bentley, noel.bentley@powerof3speaking.com


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The project is a Collective Impact Initiative designed to address systemic barriers to social inclusion of seniors 55+ and to make Surrey an inter-culturally inclusive and engaged community. This project is funded in part by the Government of Canada's New Horizons for Seniors Program.
First Name *
Last Name *
Email Address *
Phone number *
Neighbourhood you live in?  (Please note that this program is open to residents of Surrey only at this time) *
What is your age range? This first cohort will be designed specifically for Seniors 55+ (Future cohorts may include different age ranges) *
Where did you hear about Surrey SPEAKS? *
Required
If you selected 'Other' in the question above, please provide your answer here.
What is your ability with technology? *
What access to technology do you currently have? (Please check all that apply) *
Required
Do you have internet access at home? *
Have you ever used an online conference platform such as these below? (Please check all that apply) *
Required
Are you able to commit to the full 16 week program from April 20th - August 14th 2020 ? If no, please explain. *
What interests you about the Surrey SPEAKS program? *
What are you hoping to get out of being in the program? *
Are you aware that this program has a celebration at the end where everyone will share their story on stage? *
Do you have any experiences with public speaking or story telling? If so, can you please tell us about that?
What else would be helpful for us to know about you?
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