Wisconsin PATCH Workshop Request Form
To schedule a PATCH Workshop anywhere in Wisconsin, please fill out and submit this form. This form works for ALL Wisconsin PATCH Sites including: PATCH Central Wisconsin, PATCH Coulee Region, and PATCH Dane County. A Staff member from the PATCH Site nearest to you (determined by the workshop location) will be contact you directly upon receipt of this form. within 3 days to schedule your workshop.

PLEASE NOTE: Wisconsin PATCH charges for all workshops, but is waiving fees for the 2020-2021 program year. Please see details in the workshop fees section.
Organization/Agency/Group Name *
Organization/Agency/Group Type *
Primary Contact Name *
Primary Contact Title/Position
Phone Number *
Email Address *
Preferred Communication Method *
How did you hear about PATCH? *
Workshop Information
Please provide as many details about your request as possible.
Which type of workshop are you requesting? *
Expected Number of Participants *
In support of improving patient care, this activity has been planned and implemented by the University of Wisconsin–Madison ICEP and Providers and Teens Communicating for Health (PATCH). The University of Wisconsin–Madison ICEP is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. More details at https://ce.icep.wisc.edu/content/patch-for-providers-workshop. Would your group be seeking accreditation?
Which days work best for you to host the selected workshop (check all that apply)? *
What time of day works best for you to host the selected workshop? (check all that apply) *
If you are requesting a workshop for a specific day, time, and/or event please share those details below.
Workshop Logistics
Please provide complete information for all the questions below to help PATCH better prepare for your workshop. If you are wanting to do a workshop virtually please indicate that in the workshop address below.
Workshop Address/Location *
Additional Workshop Location Details (ex. parking information, building/business name, helpful instructions, etc.)
PATCH Workshops can be done virtually or in person. PATCH is able to create the virtual workshop space via Zoom or can join a platform of your choice. In-person workshops require the use of a projector and a computer with the ability to use PowerPoint and play sound. PATCH for Teens workshops may also benefit from these materials, but does not require them. Please select all of the statements that apply. *
Workshop Fee
The PATCH for Providers workshop is valued at $500 per session for up to 100 participants and the PATCH for Teens Workshop is valued at $150.

Due to the challenges many clinics, educational institutions, and organizations are facing due to the COVID-19 pandemic, Wisconsin PATCH is moving to a donation-based structure for the 2020-2021 program year. While workshop fees are waived for workshops moved to a virtual format, donations are appreciated to help cover program costs and are especially appreciated if you'd need physical workshop materials.

Please reach out to PATCH Staff at (608) 251-0139 ext. 4 or patch@wiawh.org with any questions or to discuss more.
Is your group interested in offering a donation to the PATCH Program? If so, how much would you like to contribute towards the usual workshop costs?
If you would like to donate, please visit tinyurl.com/pitchinforpatch OR indicate who we should address an invoice to and where we should send it in the space below.
Final Details
Is there anything else you'd like us to know about this workshop request? Are there any specific requests you have for PATCH?
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