Training Request Form

Thank you for your interest in hosting a We Can! training! Please use this form to request a We Can! training and corresponding exhibits or materials. NOTE ON THIS FORM: We Can! trainers provide training on using the overall We Can! program as well as on the parent and youth curricula. Use this form if you wish to host a training. If you wish to participate in a training, please email nhlbiinfo@nhlbi.nih.gov to add your name to the training waitlist. Please complete the form below and submit to We Can! by email to nhlbiinfo@nhlbi.nih.gov or fax to (202) 884-8760. You will receive prompt confirmation of receipt by email. You may expect a detailed response from We Can! within 20 business days after submitting this completed form and all supporting materials. Please feel free to contact the We Can! program staff at nhlbiinfo@nhlbi.nih.gov with questions. 1. A. We Can! Training Request Type of Training (please mark all that apply): Please mark all curricula training requested: We Can! Program Overview We Can! Parent Program Media-Smart Youth CATCH Kids Club S.M.A.R.T. Other Please note desired format for training: In-person Web-based Phone-based B. Desired length of training sessions (please include times for all that apply): We Can! Program Overview: We Can! Parent Program: Media-Smart Youth: CATCH Kids Club: S.M.A.R.T.: Other:

View descriptions of curricula on We Can! Web site: http://www.nhlbi.nih.gov/health/public/heart/obesity/weca n/whats-we-can/resources_communities.htm#implement

2. Contact Information Name and Title: Organization: Email: Phone: Address:

Current We Can! Involvement (Please mark all that apply): Intensive Community Site General Community Site City/County Partner Other (please describe): Current and past We Can! Programming: Future Plans for We Can! Programming:

3. Training Event Information Training Event Title: Training Event Date and Time: Training Event Location (Address, City, State, Type of Venue): Training Event Description and/or agenda (e.g. annual conference, independent training): Anticipated number of individual attendees: Anticipated number of organizations to attend: Anticipated geographic reach represented (Please be as specific as possible, e.g., name specific city, county, and/or states): Professional background(s) of attendees; other speakers particularly relevant to We Can!: Other Types of Training Being Offered (topic and/or organization): Key Invited Officials or Partners: Invited members of the press (groups and/or medium): Key promotional activities:

4. Preferred Response Deadline: NOTE: Requests for trainings are preferably submitted at least six months in advance. Please feel free to submit a request with fewer than six months advance notice. We Can! will make every effort to accommodate requests submitted with shorter time frames. When do you need to hear back from We Can! by?: 5. Travel & Logistical Support Available A. Can you provide any of the following travel support? Please mark all that apply: Air Lodging Ground transportation Meals Other (Please describe): If travel support is available, please identify for how many people and the source of funding: B. Can you provide any of the following exhibiting/materials support (Please mark all that apply): Purchase of We Can! Materials for Distribution Shipping to Event Return Shipping Exhibitor Fees Equipment Fees Handling, storage Fees Other (Please describe): If exhibiting/materials support is available, please identify source of funding: C. Can you provide any of the following training space & equipment? Please mark all that apply:
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Training space to accommodate all participants Tables and chairs to accommodate all participants Adequate facilities for physically disabled persons D. Can you provide any of the following audio/visual equipment? Please mark all that apply: Laptop with DVD player Number of sets: LCD Projector & Screen Number of sets: Microphone Web-conference software Teleconference capabilities E. Logistical Support: (Please mark all that apply) On-site Point of Contact at Event Name: Email: Phone: Shipping Point of Contact Name: Email: Phone: Shipping address (No P.O. Boxes please): Planning & Coordination Point of Contact Responsible for Planning with We Can! Staff Name: Email: Phone: 6. We Can! Exhibits and Materials Requested We Can! Exhibits and/or Materials Requested (please mark all that apply): Pop-up Banner (7-ft) Horizontal Banner (10-ft) Other (Please describe and note titles, quantity, language and size as appropriate):
Description of materials available on We Can! Web site at: http://www.nhlbi.nih.gov/health/public/heart/obesity/wecan/whats-wecan/resources_parents.htm