Wisconsin Alliance for Women's Health

Organization/Agency/Group Name *
Organization/Agency/Group Type *
Residency Program Professional Association Hospital Medical Group Medical Student Group Youth Group or High School Other
Primary Contact Name *
Primary Contact Title
Contact Phone Number * ### - ### - ####
Contact Email *
Preferred communication: *
Email Phone
Workshop Request
Type of Workshop Requested: *
Keep'n It Real With Your Doctor Workshop (for Youth) Keeping It Real With Your Patients Workshop (for Health Care Providers) Keeping it Real With Your Patients Workshop PLUS an Adolescent Standardized Patient Session (for Health Care Providers)
Preferred Days (check all that apply)
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Preferred Month (check all that apply)
Sept, 2011 Oct, 2011 Nov, 2011 Dec, 2011 Jan, 2012 Feb, 2012 March, 2012 April, 2012 May, 2012 June, 2012 July, 2012
Preferred Time of Day (check all that apply)
Morning Noon Evening
To request a specific day, time and/or event, please share the details below:
Workshop Details
Location of Workshop:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Number of Expected Participants

WAHCCP Workshops can accommodate groups of 10 to 60 participants, however, the preferred size is between 20 and 40 participants.
Specific Requests:

WAHCCP may be able to customize your workshop so that it best meets the needs of your audience members. Please let us know if you have specific topics or issues you would like addressed.
Do Not Fill This Out

Wisconsin Alliance for Women's Health

Workshop Request

Workshop Details