UMedics Workshop Request Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

This is a workshop request form for groups interested in hosting a Ujimaa Medics (UMedics) workshop.

Please note:
* This form should be completed at least three (3) weeks in advance of your workshop request
* Workshops must engage a minimum of 5 people and a maximum of 60 people at a time
* We reserve the right to reschedule or decline workshops

If you do not hear back from us within 7 business after submitting your form, please email...

General mailbox, for general inquiries .......................................admin@umedics.org
Raven, Quality Director, for CPR and Community Event..............raven@umedics.org
JoeY, Training Coordinator, for all other requests...........................joe@umedics.org

********************************************************************************************

Need CPR, AED and FIRST AID certification? Please copy and paste the link below:

https://forms.gle/mPbd9gTgabr7VW6A6

Want Ujimaa Medics at to show up at a community event (health and career fairs, festivals, public actions etc)? Please copy and paste the link below:

https://forms.gle/cGNaX9bgGaG5i7qJ6

********************************************************************************************

Ujimaa Medics is currently booked through August 8th, 2026 for the following offerings...

Community Safety Planning
Protestor Health and Safety
Gunshot Wound First Response Workshop

Email *

Phone number *

Please write your name
*

What are the best ways to contact you?

Check all items which apply to you.

Phone call

Text messages

Facebook

Instagram

Other:

Name of organization

Please list the name of the organization or group who will be receiving this workshop.

What is your role in the organization?

What type of organization is it?

Check all which apply.

Nonprofit (a social service, volunteer, or charitable organization)

For Profit (a business, corporation, or enterprise)

Activist/Political Organization (a justice-centered, ideological, or politically conscious organization)

Community Operated (a block club, neighborhood association, or demographically-based organization)

School (K-12, college class, homeschool network, etc)

Place of worship

My family

Other:

Please give a brief description of your organization or post a link to your website (if there is one)

Explain who you are and what you do.

What are you interested in learning? *

Basic Gunshot Wound First Response (in-person only)

Asthma Community Care (online or in-person)

Protestor Health & Safety (online or in-person)

Community Safety Planning (online only)

Collective Care and Support Network Mapping (online or in-person)

CPR, First Aid and AED

Overdose First Aid (in-person only)

Not sure, can we talk about it?

Other:

Who are you hosting this workshop for? *

Internal organization (members, staff, or clients within your organization)

External community (people in your community)

Organizational and community members

Other:

How many people do you anticipate will attend the workshop? *

Location of the workshop *

Please list the full address of the workshop and whether it's indoor or outdoor (Example: outdoors at 5XXX W Van Buren, Chicago, IL 60644)

When would you like to host? *

Please look to the top of this form for any notes on our availability!

YYYY

Time

What time works best for you? *

Time

What alternate date would you like to host? *

Please select a secondary date.

YYYY

What is your budget? We may request that organizations with a large operating budget pay a fee on a sliding scale. We place high value on the labor and precious time of our members. *

My organization is requesting a free, barter, or low fee workshop (priority for Black, Brown or Indigenous-led groups)

My organization has a budget to pay UMedics trainers a fee for their services

Other:

How did you hear about us? Please print name or give a description. *

Does your organization need support with communications and promotional materials?

We can provide a social media graphic, newsletter graphic, and a one-pager on Ujimaa Medics to circulate within your organization.

Yes, all materials (Social media graphic, newsletter graphic, and a one-pager)

Yes, just a social media and newsletter graphic

No, we’re all good

Other:

Do you have any additional notes, questions, or points we should consider ahead of us meeting to discuss your request?

Send me a copy of my responses.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Forms