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 syerramilli@columbus.k12.oh.us if you have any questions.


Click each item below to add your answer.
General Information
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 *
Contact Information
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 *
Administrative Approval
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: *
Program Topics
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.
Required
Programming Details
Date of the Wellness Programming *
MM
/
DD
/
YYYY
Start Time of the Wellness Programming *
Time
:
Duration of the Wellness Programming *
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).
Additional Information
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?
Comments
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