Team Member Form for the COACH Program
To be completed by each member of an applying COACH Program team
Name:
Your answer
Name of coalition/collaborative:
Your answer
What agency or organization do you represent or work for? (if applicable)
Your answer
Email address:
Your answer
Phone number:
Your answer
Mailing address (street address):
Your answer
City:
Your answer
State:
Your answer
Zip code:
Your answer
County:
Your answer
Have you participated in the Community Teams Program?
What do you hope to gain by participating in the COACH Program?
Your answer
How would you describe your main contributions to the coalition/collaborative? (examples: skills, knowledge, time, money, connections, resources, perspectives)
Your answer
One team member should indicate that they are the primary contact for your team. Primary contact responsibilities include: Serving as communication point person and liaison with HWLI; scheduling and coordinating site visits; ensuring team members are participating in COACH activities; and serving as contact person for follow-up evaluation. Are you the primary contact for the team?
To get the most out of the experience, participants are encouraged to take full advantage of COACH Program site visits and the COACH Summit.
Members of COACH teams are expected to 1) identify team learning priorities and team policy, systems, and environmental change goals, and communicate them to program staff; 2) actively participate in the COACH Summit, site visits, and PSE action plan implementation; 3) COACH team leads or one team member is expected to participate COACH Community Calls and maintain an open line of communication for peer-to-peer learning and regional collaboration and alignment; 4) share information with and engage the broader coalition; 5) complete assignments such as viewing webinars; 6) contribute actively to developing, implementing and evaluating the team’s selected policy, systems, and environmental change goals and objectives; 7) meet as a team on a monthly basis; 8) COACH team leads are expected to have quarterly calls (every three months) with their HWLI coach to assess progress and needs of the team.
Team member signature:
Your answer
EMPLOYER STATEMENT OF SUPPORT I HAVE DISCUSSED THE HEALTHY WISCONSIN LEADERSHIP INSTITUTE’S COMMUNITY TEAMS PROGRAM WITH MY EMPLOYER/SUPERVISOR.
MY EMPLOYER UNDERSTANDS THE TEAM MEMBER REQUIREMENTS AS DESCRIBED IN THE PROGRAM APPLICATION. THIS INCLUDES; IN-STATE TRAVEL TO ATTEND SIX SITE VISITS OVER THREE YEARS; PARTICIPATION IN A TWO-DAY SUMMIT; PARTICIPATION IN WEBINARS; AND TIME DEVOTED TO ASSIGNMENTS AND WORK ON THE TEAM’S ACTION PLAN. MY EMPLOYER/SUPERVISOR UNDERSTANDS THAT TEAM MEMBERS ARE RESPONSIBLE FOR ALL EXPENSES RELATED TO TRAVEL, LODGING, AND THEIR ACTION PLAN. THE HEALTHY WISCONSIN LEADERSHIP INSTITUTE COVERS THE COST OF INSTRUCTIONAL MATERIALS AND PROGRAMMING, FACILITY EXPENSES FOR WORKSHOPS, AND FEES FOR GUEST FACULTY AND EXPERTS WHO PROVIDE INSTRUCTION AND TECHNICAL ASSISTANCE. MY EMPLOYER/SUPERVISOR FULLY SUPPORTS MY APPLICATION FOR THIS PROFESSIONAL DEVELOPMENT PROGRAM.
Employer/Supervisor name:
Your answer
Employer/Supervisor phone:
Your answer
Employer/Supervisor email:
Your answer
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