COYL Partner Form

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COYL Partner Form

Thank you for your interest in being a partner to Conversation of Your Life (COYL), a program of the New Jersey Health Care Quality Institute's Mayors Wellness Campaign.

To learn more about COYL and utilize our resources, visit: https://www.njhcqi.org/coyl/

What is your name?

What organization(s) are you employed by or affiliated with?

What role do you fill at your organization(s)?

What is your email address?

Would you like to be added to our mailing list?

Yes

Clear selection

What is your phone number?

What is your preferred form of contact?

Text

Phone call

Clear selection

What capacity would you like to partner with COYL? (Please select all that apply)

Presenter/Expert Speaker

Organizer of events

Communications/Marketing support

Host Site for COYL events

Volunteer at COYL events

COYL advocate on a local MWC committee (Please indicate in comments what town(s) you would like to work with specifically)

Sponsor for COYL events

Other:

If you selected presenter, what topics would you feel comfortable speaking on? (select all that apply)

Discussion topics descriptions:

Introduction to Advance Care Planning

Understanding the Benefits of Hospice

Palliative Care

Choosing a Healthcare Proxy

The Five Wishes Advance Care Plan

POLST

Eldercare

MAID: Medical Aid in Dying

Movie Screenings, Book discussions, game "nights"

Funeral Planning

Other:

What counties would you be able to participate in? (Select all that apply)

Virtual

Any County

Atlantic

Bergen

Burlington

Camden

Cape May

Cumberland

Essex

Gloucester

Hudson

Hunterdon

Mercer

Middlesex

Monmouth

Morris

Ocean

Passaic

Salem

Somerset

Sussex

Union

Warren

I am interested in organizing or volunteering at a program during:

National Health Care Decisions Day (April)

Hospice and Palliative Care Month (November)

Both

N/A

Clear selection

My organization is organizing programs during:

National Health Care Decisions Day (April)

Hospice and Palliative Care Month (November)

Both

N/A

Clear selection

Additional Questions/Comments

If you would like to receive a COYL welcome kit, please provide your mailing address below.

Submit

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