Training Request Form

Thank you for your interest in hosting a We Can! training! Please use this form to request a We Can!
training and corresponding exhibits or materials.

NOTE ON THIS FORM:

We Can! trainers provide training on using the overall We Can! program as well as on the parent and
youth curricula. Use this form if you wish to host a training. If you wish to participate in a training, please
email nhlbiinfo@nhlbi.nih.gov to add your name to the training waitlist.

Please complete the form below and submit to We Can! by email to nhlbiinfo@nhlbi.nih.gov or fax to
(202) 884-8760. You will receive prompt confirmation of receipt by email. You may expect a detailed
response from We Can! within 20 business days after submitting this completed form and all supporting
materials. Please feel free to contact the We Can! program staff at nhlbiinfo@nhlbi.nih.gov with
questions.

1. We Can! Training Request

A. Type of Training (please mark all that apply):

Please mark all curricula training requested:

We Can! Program Overview
We Can! Parent Program View descriptions of curricula on We Can! Web site:
Media-Smart Youth http://www.nhlbi.nih.gov/health/public/heart/obesity/weca
CATCH Kids Club n/whats-we-can/resources_communities.htm#implement
S.M.A.R.T.
Other      

Please note desired format for training:

In-person
Web-based
Phone-based

B. Desired length of training sessions (please include times for all that apply):

We Can! Program Overview:      

We Can! Parent Program:      
Media-Smart Youth:      
CATCH Kids Club:      
S.M.A.R.T.:      
Other:

2. Contact Information
Name and Title:     
Organization:     
Email:     
Phone:     
Address:     

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Current We Can! Involvement (Please mark all that apply):
Intensive Community Site
General Community Site
City/County
Partner
Other (please describe):      

Current and past We Can! Programming:     

Future Plans for We Can! Programming:      

3. Training Event Information

Training Event Title:      

Training Event Date and Time:     
Training Event Location (Address, City, State, Type of Venue):     
Training Event Description and/or agenda (e.g. annual conference, independent training):     
Anticipated number of individual attendees:     
Anticipated number of organizations to attend:     
Anticipated geographic reach represented (Please be as specific as possible, e.g., name specific city,
county, and/or states):      
Professional background(s) of attendees; other speakers particularly relevant to We Can!:     
Other Types of Training Being Offered (topic and/or organization):     
Key Invited Officials or Partners:     
Invited members of the press (groups and/or medium):      
Key promotional activities:     

4. Preferred Response Deadline:     

NOTE: Requests for trainings are preferably submitted at least six months in advance. Please feel free to
submit a request with fewer than six months advance notice. We Can! will make every effort to
accommodate requests submitted with shorter time frames.

When do you need to hear back from We Can! by?:      

5. Travel & Logistical Support Available

A. Can you provide any of the following travel support? Please mark all that apply:
Air
Lodging
Ground transportation
Meals
Other (Please describe):     

If travel support is available, please identify for how many people and the source of funding:     

B. Can you provide any of the following exhibiting/materials support (Please mark all that apply):
Purchase of We Can! Materials for Distribution
Shipping to Event
Return Shipping
Exhibitor Fees
Equipment Fees
Handling, storage Fees
Other (Please describe):     

If exhibiting/materials support is available, please identify source of funding:     

C. Can you provide any of the following training space & equipment? Please mark all that apply:

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 Training space to accommodate all participants
Tables and chairs to accommodate all participants
Adequate facilities for physically disabled persons

D. Can you provide any of the following audio/visual equipment? Please mark all that apply:
Laptop with DVD player Number of sets:      
LCD Projector & Screen Number of sets:      
Microphone
Web-conference software
Teleconference capabilities

E. Logistical Support: (Please mark all that apply)

On-site Point of Contact at Event
Name:     
Email:     
Phone:      
Shipping Point of Contact
Name:     
Email:     
Phone:      
Shipping address (No P.O. Boxes please):      
Planning & Coordination Point of Contact Responsible for Planning with We Can! Staff
Name:     
Email:     
Phone:     

6. We Can! Exhibits and Materials Requested

We Can! Exhibits and/or Materials Requested (please mark all that apply):
Pop-up Banner (7-ft)
Horizontal Banner (10-ft)
Other (Please describe and note titles, quantity, language and size as appropriate):     

Description of materials available on We Can! Web site at:

http://www.nhlbi.nih.gov/health/public/heart/obesity/wecan/whats-we-
can/resources_parents.htm