Change Impact PD Request Form

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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 *

Contact Name *

Contact Email *

Contact Phone Number *

Who is the audience for the professional development you are seeking? Select all that apply. *

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

What age group(s) does the audience work with? *

How many people will participate in professional development? *

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. *

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: https://www.changeimpact.net/live-pd.html). *

What specific goals do you have for the workshop? *

What professional development format are you interested in? Select all that apply. *

In-person training

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 in-person training, please indicate the location if you know it.

For live training, approximately when would you like to have the professional development delivered? *

What information about the training, audience, and/or the communities you serve would be helpful for us to know?

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