PATCH for Providers Workshop Request Form
To schedule a PATCH for Providers Workshop, please fill out and submit this form. You will be contacted within 3 days to schedule your workshop. If you have questions or would like more information, please contact PATCH Staff at (608) 251-0139 ext. 4 or firstname.lastname@example.org.
PLEASE NOTE: PATCH charges for all workshops.
The PATCH for Providers workshop fee is $500. Upon scheduling a workshop you will be invoiced a $250 non-refundable deposit and after the workshop for the additional $250.
The PATCH for Teens workshop fee is $150. Upon scheduling a workshop you will be invoiced for the full amount.
This fee covers staff time, Teen Educator training and time, materials, maintenance of continuing education credits (applies to PATCH for Providers workshop only), local travel, and program evaluation and improvement. Workshops outside of the Dane County area may be charged an additional travel fee.
Please select from the list below
Residency Program or Medical Education Program
Hospital or Clinic
Youth Organization or School Club
If you selected "other" above, please tell us more.
Primary Contact Name
Primary Contact Title
Contact Phone Number
Preferred Communication Method
How did you hear about PATCH?
Do Not Fill This Out