Wisconsin PATCH Workshop Request
Please complete this form to schedule a PATCH workshop in the state of WISCONSIN.  A staff member from the PATCH Site nearest to you (determined by the workshop location) will contact you directly upon receipt of this form. This form works for ALL Wisconsin PATCH Sites including: PATCH Green Bay, PATCH La Crosse, PATCH Madison, PATCH Milwaukee, and PATCH Wausau.  
Sign in to Google to save your progress. Learn more
Workshop Information
Please provide as many details about your request as possible.
Organization/Agency/Group Name *
Organization/Agency/Group Type *
Required
Primary Contact Name *
Primary Contact Title/Position
Phone Number *
Email Address *
Preferred Communication Method *
Required
How did you hear about PATCH? *
Which type of workshop are you requesting? *
Required
Expected Number of Participants *
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.
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.
PATCH Workshops are intended to be delivered in person, but can also be done virtually. In-person workshops require the use of a projector and a computer with the ability to use PowerPoint. Please select all of the statements that apply. *
Required
Workshop Address or Virtual Platform *
Additional Workshop Location Details (ex. parking information, building/business name, helpful instructions, etc.)
Workshop Fees
The PATCH for Providers workshop is valued at $500 per session for up to 100 participants.
The PATCH for Teens: Peer-to-Peer Workshop is valued at $150 per session.

These fees help PATCH cover program costs and maintain accreditation status. However, we understand that many organizations face financial barriers for ongoing learning and professional development. For that reason, PATCH Wisconsin offers flexible pricing on a sliding fee scale, and may waive the fee completely, depending on your organization's budget. We are happy to find a rate that works best for your organization.

Please reach out to PATCH Staff at staff@wipatch.org with any questions or to discuss more.
Please indicate below the preferred fee structure for your PATCH workshop
If you are able to pay a workshop fee, how much will your organization contribute to the workshop fee? An invoice will be generated once the workshop is confirmed.
If you are able to pay a workshop fee, where should we send the invoice and to whom should it be addressed? Please include name, email address, and physical address.
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?
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Embolden WI. Report Abuse
Google Forms