Request an AWP Education Program: Healthcare Programs

Please provide the following information to request an AWP Education Program for your healthcare team, facility, and/or organization.

Once we have received your completed Program Request Form, a member of AWP's Education Team will contact you within 1-2 business days.

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* 1. Your First & Last Name

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* 2. Role / Title

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* 3. Healthcare Organization / Facility Name

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* 4. Email Address

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* 5. Phone Number

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* 6. What topic(s) would you like to see included in your program? (please select all that apply)

Domestic Violence, Human Trafficking & A Woman's Place 101

Screening for Domestic Violence & Human Trafficking in Healthcare Settings

Domestic Violence & Traumatic Brain Injury

Domestic Violence During Pregnancy

Domestic Violence, Older Adults, & Elder Abuse

Domestic Violence in LGBTQ+ Relationships

Domestic Violence & Persons with Disabilities

Teen Dating Violence

Other (please specify)

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* 7. Who will be attending this program? (please select all that apply)

Healthcare Staff & Professionals

Patients

Caregivers & Family Members

Community Members

Other (please specify)

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* 8. Approximately how many participants do you expect to attend this program?

1-15 participants

15-30 participants

30+ participants

Other (please specify)

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* 9. Our programs can be structured based on the needs, interests, & availability of any audience. AWP's Education Team can provide any of the following program structures listed. Please select any that interest you:

One-Time Workshop / Event

Monthly / Quarterly Trainings

Lunch & Learns

Table / Poster Display

Other (please specify)

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* 10. Programs can be offered in 30-, 60-, and 90-minute formats. What format do you prefer?

30-minute

60-minute

90-minute (recommended)

Other (please specify)

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* 11. Will this program be facilitated online or in-person?

Online

In-Person

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* 12. If online, what platform will be used?

Microsoft Teams

Google Classroom

Zoom

Doxy.Me

I am not requesting an online program.

Other (please specify)

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* 13. If in-person, will a computer & projector with internet, audio, & video capabilities be availble for use?

Yes

I am not requesting an in-person program.

Other (please specify)

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* 14. Please list the date / week / month for which you would like to schedule your program.
NOTE: We cannot guarantee this date / week / month, but we will do our very best! All scheduling is based on the availability of our team of Community Educators.

Request an AWP Education Program: Healthcare Programs

Question Title

* 1. Your First & Last Name

Question Title

* 2. Role / Title

Question Title

* 3. Healthcare Organization / Facility Name

Question Title

* 4. Email Address

Question Title

* 5. Phone Number

Question Title

* 6. What topic(s) would you like to see included in your program? (please select all that apply)

Question Title

* 7. Who will be attending this program? (please select all that apply)

Question Title

* 8. Approximately how many participants do you expect to attend this program?

Question Title

* 9. Our programs can be structured based on the needs, interests, & availability of any audience. AWP's Education Team can provide any of the following program structures listed. Please select any that interest you:

Question Title

* 10. Programs can be offered in 30-, 60-, and 90-minute formats. What format do you prefer?

Question Title

* 11. Will this program be facilitated online or in-person?

Question Title

* 12. If online, what platform will be used?

Question Title

* 13. If in-person, will a computer & projector with internet, audio, & video capabilities be availble for use?

Question Title

* 14. Please list the date / week / month for which you would like to schedule your program.
NOTE: We cannot guarantee this date / week / month, but we will do our very best! All scheduling is based on the availability of our team of Community Educators.

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* 15. How did you hear about AWP's Education Programs?

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* 16. Please list any questions, concerns, or special requests you would like to share with AWP's Education Team:

Question Title

* 1. Your First & Last Name

Question Title

* 2. Role / Title

Question Title

* 3. Healthcare Organization / Facility Name

Question Title

* 4. Email Address

Question Title

* 5. Phone Number

Question Title

* 6. What topic(s) would you like to see included in your program? (please select all that apply)

Question Title

* 7. Who will be attending this program? (please select all that apply)

Question Title

* 8. Approximately how many participants do you expect to attend this program?

Question Title

* 9. Our programs can be structured based on the needs, interests, & availability of any audience. AWP's Education Team can provide any of the following program structures listed. Please select any that interest you:

Question Title

* 10. Programs can be offered in 30-, 60-, and 90-minute formats. What format do you prefer?

Question Title

* 11. Will this program be facilitated online or in-person?

Question Title

* 12. If online, what platform will be used?

Question Title

* 13. If in-person, will a computer & projector with internet, audio, & video capabilities be availble for use?

Question Title

* 14. Please list the date / week / month for which you would like to schedule your program. NOTE: We cannot guarantee this date / week / month, but we will do our very best! All scheduling is based on the availability of our team of Community Educators.

Question Title

* 15. How did you hear about AWP's Education Programs?

Question Title

* 16. Please list any questions, concerns, or special requests you would like to share with AWP's Education Team:

* 14. Please list the date / week / month for which you would like to schedule your program.
NOTE: We cannot guarantee this date / week / month, but we will do our very best! All scheduling is based on the availability of our team of Community Educators.