Change Impact PD Request Form
* Required
Thanks for your interest in Change Impact's professional development! Please complete this short form and we will reach out with more information.
Organization Name
*
Your answer
Contact Name
*
Your answer
Contact Email
*
Your answer
Contact Phone Number
*
Your answer
Who is the audience for the professional development you are seeking? Select all that apply.
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Central agency staff
Single program site
Senior managers (e.g., Directors, Site Supervisors, Program Directors)
Front-line staff (people working directly with clients)
Other:
Required
How many people will participate in professional development?
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Up to 20
21-50
50-99
100 or more
Will there be anyone participating in professional development who requires special accommodations? If so, please describe.
Your answer
Have you identified topics from the Change Impact website that you would like to focus on? If so, please list titles or themes here. (see:
http://www.changeimpact.net/professional-development.html
)
Your answer
What prompted the need for this professional development?
Your answer
What professional development format are you interested in? Select all that apply.
*
In-person training (not currently offered due to COVID-19)
Virtual live training (staff come together at a scheduled time)
Self-paced online training (staff take the course on their own schedule)
One-to-one or small group coaching
Other:
Required
For live training, approximately when would you like to have the professional development delivered?
*
Your answer
Is there anything else you would like us to know?
Your answer
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