COYL Workshop Request Form

Thank you for your interest in hosting a Conversations of Your Life (COYL) workshop. COYL workshops and presentations help community members learn about and engage in advance care planning, including understanding health care options, identifying personal priorities, and accessing resources to support informed decision-making.

To ensure we can coordinate speakers, prepare materials, and provide the best possible program, please submit this request at least 6 weeks before your preferred event date.

Once your request is received, a member of our team will follow up to confirm details, discuss logistics, and answer any questions within 2-4 business days. We look forward to collaborating with you to offer a meaningful COYL workshop in your community.

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* 1. Organization/Host Site Name

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* 2. Contact Person

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* 3. Contact Email

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* 4. Contact Phone Number

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* 5. Preferred Program Date & Time

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* 6. Alternative Program Date & Time

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* 7. Length of time for workshop (Typically workshops are between 45 minutes and 1 hour)

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* 8. Location/Venue Name and Address

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* 9. Program Delivery Method

In-person

Virtual

Hybrid

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* 10. Program Format

One-time workshop

Multi-part series

Other (please specify)

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* 11. Type of Program

Panel presentation

Informational presentation / lecture

Film screening & discussion

Community book read

Game night

Other (please specify)

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* 12. Workshop Topic(s) Requested (Check all that apply)

Introduction to Advance Care Planning

Understanding the Benefits of Hospice and Palliative Care

Choosing a Healthcare Proxy

ACP Documents (POLST, Goals of Care, Five Wishes)

Eldercare

MAID: Medical Aid in Dying

Funeral Planning

Other (please specify)

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* 13. Requested Speaker(s) speciality/type

Hospice or palliative professional

End-of-Life Doula

Faith leader

Eldercare attorney

Medical Aid in Dying expert

End-of-life advocate

Other (please specify)

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* 14. Target Audience/Communities you Wish to Reach

Older adults / seniors

Veterans

Faith-based communities

Caregivers

Health care professionals

Specific cultural or language communities (please specify below)

Other (please specify)

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* 15. Program Goals / Focus Areas (Example: “Educate residents on hospice benefits” or “Facilitate advance care planning conversations.”)

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* 16. Anticipated Audience Size

Fewer than 10 participants

10-24 participants

25-49 participants

50-74 participants

75-99 participants

100+ participants

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* 17. Materials Needed (check all that apply)-Optional

Five Wishes documents

COYL Bookmarks

Resource handouts

Other (please specify)

COYL Workshop Request Form

Question Title

* 1. Organization/Host Site Name

Question Title

* 2. Contact Person

Question Title

* 3. Contact Email

Question Title

* 4. Contact Phone Number

Question Title

* 5. Preferred Program Date & Time

Question Title

* 6. Alternative Program Date & Time

Question Title

* 7. Length of time for workshop (Typically workshops are between 45 minutes and 1 hour)

Question Title

* 8. Location/Venue Name and Address

Question Title

* 9. Program Delivery Method

Question Title

* 10. Program Format

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* 11. Type of Program

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* 12. Workshop Topic(s) Requested (Check all that apply)

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* 13. Requested Speaker(s) speciality/type

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* 14. Target Audience/Communities you Wish to Reach

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* 15. Program Goals / Focus Areas (Example: “Educate residents on hospice benefits” or “Facilitate advance care planning conversations.”)

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* 16. Anticipated Audience Size

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* 17. Materials Needed (check all that apply)-Optional

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* 18. Additional Notes / Special Requests