CCS Wellness Programming Request Form
Use this form to request CCS Wellness Programming. Our Wellness Initiative hosts programming for staff events on days including, but not limited to: Professional Development days, Records days, staff meetings, and afterschool. Please contact
if you have any questions.
Click each item below to add your answer.
Name of CCS location hosting Wellness Programming
CCS location front office phone number
Street address of CCS location hosting Wellness Programming
Zip code of CCS location
Region of CCS location
First & last name of person requesting the Wellness Programming
CCS email address of person requesting the Wellness Programming
Work phone number or direct extension number of person requesting the Wellness Programming
Preferred method of contact for person requesting the Wellness Programming
CCS email address
Work phone number or direct extension number
CCS location administrator's first & last name
Name of Principal or Supervisor
Has the CCS location administrator approved the request?
Wellness Programming Information
The Wellness Programming will be held during:
Professional Development Day
Please select topic that you would like the CCS Wellness Team to present to your group. See examples for subjects relating to the program topic.
Type of Programming requested
Please check all that apply.
Financial Literacy (managing money, invest and use credit, money saving tips, financial wellness)
Leadership (personal and professional leadership)
Nutrition (healthy eating during your busy day, eating better on a budget, mindful eating, packing a healthy lunch)
Personal Empowerment (finding your purpose, resiliency, positive thinking, prioritizing your life)
Physical Activity (fitting fitness into your busy day, exercising at home, stretching, weight management )
Self-Reflection (diversity & inclusion practices using art, critical thinking, and storytelling to support creative learning)
Stress Prevention (managing stress, resiliency, developing work/life balance, goal- setting)
Team Building (conflict resolution, motivation, customer service)
Urban Zen Integrative Therapy (program with aromatherapy, gentle movements, yoga postures, mindfulness, and breathing exercises)
Wellbeing (wellness in the workplace, lifestyle changes, developing your personal wellness plan)
Yoga/Mindfulness (staff mindfulness & self care, incorporating mindful moments and yoga breaks in classrooms)
Date of the Wellness Programming
Start Time of the Wellness Programming
Duration of the Wellness Programming
I have included a special time request in the comments box
Room name and/or number to hold the Wellness Programming
Ideally, the room should include a smart board or projector, outlets available to plug in computers/laptops. The room should be large enough to accommodate the number of staff attending the program.
Type of staff attending the Wellness Programming
Please specify the audience (ex: teachers, principals, secretaries, bus drivers etc.)
Number of staff members attending the Wellness Programming
Please provide your best estimate on the number of staff attending the program so we can plan for enough materials (handouts, wellness incentives).
To gain a better understanding of the specific wellness needs of the audience, please respond the the following questions.
Describe some everyday challenges that the staff members attending the Wellness Programming, may encounter in their work life.
What outcomes are you looking to achieve with this Wellness Programming?
What are a few things that would make this Wellness Programming successful for your staff?
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