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.

The PATCH for Providers workshop fee is $500 for up to 100 participants. Upon scheduling a workshop you will be invoiced a $250 non-refundable deposit and after the workshop for the additional $250. Groups larger than 100 should reach out to us directly for pricing at patch@wiawh.org.

The PATCH for Teens workshop fee is $150. Upon scheduling a workshop you will be invoiced for the full amount.

This fee covers staff time, Teen Educator training and time, materials, maintenance of accreditation, local travel, program evaluation, and quality improvement. Workshops outside of an existing PATCH program area may be charged an additional travel fee. 
Organization/Agency/Group Name *
Your answer
Organization/Agency/Group Type *
Required
Primary Contact Name *
Your answer
Primary Contact Title/Position
Your answer
Phone Number *
Your answer
Email Address *
Your answer
Preferred Communication Method *
Required
How did you hear about PATCH? *
Your answer
Workshop Information
Please provide as many details about your request as possible.
Which type of workshop are you requesting? *
Required
Expected Number of Participants *
Your answer
The PATCH for Providers workshop is currently under review for accreditation renewal to provide CME or CNE credits. If available, would any of your participants use this credit? *
Required
Which days work best for you to host the selected workshop (check all that apply)? *
Required
What time of day works best for you to host the selected workshop? (check all that apply) *
Required
If you are requesting a workshop for a specific day, time, and/or event please share those details below.
Your answer
Workshop Logistics
Please provide complete information for all the questions below to help PATCH better prepare for your workshop.
Workshop Address *
Your answer
Additional Workshop Location Details (ex. parking information, building/business name, helpful instructions, etc.)
Your answer
PATCH for Provider 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. *
Required
Workshop Fee
Each PATCH Site is affiliated with local nonprofit organizations. In order to cover program costs, PATCH sites charge for all workshops.

The PATCH for Providers workshop fee is $500 for up to 100 participants. Upon scheduling a workshop you will be invoiced a $250 non-refundable deposit and after the workshop for the additional $250. Groups larger than 100 will need to work with their local PATCH Site to determine cost.

The PATCH for Teens workshop fee is $150. Upon scheduling a workshop you will be invoiced for the full amount.

This fee covers staff time, Teen Educator training and time, materials, maintenance of accreditation, local travel, and program evaluation and improvement. Workshops outside of the Dane County or Marathon County area may be charged an additional travel fee.

Please reach out to PATCH Staff at (608) 251-0139 ext. 4 or patch@wiawh.org with any questions.
What is the name of the person in your organization who should be billed on the invoice? *
Your answer
What organizational address should be included on the invoice? *
Your answer
Where should we e-mail the invoice once a workshop has been successfully scheduled? *
Your answer
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?
Your answer
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