Leader Portal > Schedule a Workshop Schedule a Workshop Here are a few things to keep in mind: Please plan your workshops at least 12 weeks in advance. Must have current implementation site agreement First and Last Name* Email* Phone*Which program will you be delivering?CDSMP? CDSMP CDSMP Virtual In-Person Toolkit with Weekly Leader Calls Tomando Control de su Salud? Tomando Control de su Salud Tomando Control de su Salud Virtual In-person Toolkit with Weekly Leader Calls DSMP? DSMP DSMP Virtual In-Person Toolkit with Weekly Leader Calls CPSMP? CPSMP CPSMP Virtual In-Person Toolkit with Weekly Leader Calls CTS? CTS CTS Virtual In-Person wCDSMP? wCDSMP wCDSMP Virtual In-Person BBC? Building Better Caregivers BBC Virtual In-Person WWE? WWE CCG? Camine Con Gusto CCG In-Person EnhanceFitness? EnhanceFitness EnhanceFitness Virtual In-Person TaiChi? Tai Chi for Arthritis and Fall Prevention TaiChi In-Person Are you able to provide a video-conference link?* I am capable of scheduling / creating my own video-conference link (ex: Zoom) I do not have the capability to schedule video-conference sessions and request assistance from BCBH-SD/SDSU Extension Video-Conference Link*Please schedule the video-conference (ex: Zoom) sessions for your virtual workshop and copy/paste the link here Meeting ID Conference Phone Number(option to join audio by phone) Site Location / Name* Site Location Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Site Contact Name* Site Contact Phone Number*Site Contact Email* Name and Title of Signing Authority* (Who needs to sign the Implementation Site Agreement, ex: Activities Director, Secretary, CEO, General Manager, etc.)Email of Signing Authority* Workshop Kit DeliveryWhere do you want the Workshop Kit to be delivered? The Workshop Kit will include all the paper forms for participants and leaders (example: attendance form, participant surveys, handouts, etc). To the site indicated above To another location (Cannot Ship to PO Box Addresses) Workshop Kit Shipping Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Who will be facilitating the workshop?Leader #1 (First/Last Name) Leader #2 (First/Last Name) Leader #3 (First/Last Name) Will this workshop be open to the public? YES NO Certificates are given to each participant in your workshop after the last session (Certificate of Completion – attended at least 12/18 sessions). Select your preference below:Certificate choice: Include Certificates in my Workshop Kit. I understand that my co-leader and I will be responsible for filling them in and handing them out to participants during Session 6 of the workshop. I want the Enrollment Coordinator to mail the Certificates to my participants. The certificates will be sent after Session 6 and shipping will take approximately 1-2 weeks. Where is the workshop being held?Facility Name Address Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Type of facility (choose only one): Residential Center Educational Center Workplace Library Senior Center Tribal Center Church Where do you want your Workshop Kit shipped?*Workshop Kits include participant and leader handouts needed for delivering in-person workshops. Same address as above Different address Shipping Address for Workshop Kits* Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code For In-person Walk With Ease ONLY: Alternative LocationThe alternative location will serve as a location when outside walking can’t take place.Workshop DatesWorkshop Start Date MM slash DD slash YYYY Workshop End Date MM slash DD slash YYYY Time Hours : Minutes AM PM AM/PM Time Zone MDT CDT Workshop Start Time Hours : Minutes AM PM AM/PM Workshop End Time Hours : Minutes AM PM AM/PM Day(s) of the Week Monday Tuesday Wednesday Thursday Friday Will you be offering a session Zero? Yes No Session Zero Date* MM slash DD slash YYYY Zero Session Start Time Hours : Minutes AM PM AM/PM Zero Session End Time Hours : Minutes AM PM AM/PM Additional NotesCAPTCHANameThis field is for validation purposes and should be left unchanged. 66651
