COPSA Training Request Form - Care 2 Caregivers

Rutgers the State University of New Jersey COPSA Institute for Alzheimer’s disease and Related Disorders Rutgers University Behavioral Health Care Training, Education & Consultation Request Form

COPSA offers a variety of comprehensive and quality trainings, education and consultation services to meet the needs of professionals and caregivers working with aging adults. Minimum class sizes (12 or more) are required to schedule trainings and education services. Requests are granted based on the availability of COPSA trainers and site professional development needs.

Training, Education & Consultation Request Form must be submitted thirty (30) business days before the anticipated event date. Event must be made available to the public unless otherwise determined with COPSA.

Requesting Agency Name *

Agency mailing information *

Street address, State and Zip Code

Name of Contact Person *

Position/Title *

Contact Email *

Contact Phone *

Agency make-up *

Senior Center
Nursing Home Facility
Non-Profit Organization
NJ State Department
County Department
Other

Please check all that apply

Audience Make Up

Number of Older Adults in Care *

Number of Professionals/Staff *

Number of Caregivers *

Total Number *

Event Information

Event Type *

Select All
Training
Education
Consultation

Check all that apply

Target date for start of event *

Target date for event completion *

Please list alternate dates should your first date not be available *

Description of request and/or topic *

(for example: Alzheimer’s disease, 2-hour training, consultation with seniors)

What previous supports has this group received in this area? *

Describe intended department/staff/group *

Directors
Case Managers
Clinical Staff
Social Workers
Seniors
Other

Describe intended department/staff/group (Other) *

Describe intended department/staff/group *

Select All
One-day Training/Education
Senior Support Group
Conference
Symposium
Keynote Speaker
More than one-day

Describe intended department/staff/group - Number of sessions *

Describe intended department/staff/group - Number of days *

What is the expected number of participants? *

Best time to conduct training *

:

Start

Best time to conduct training *

:

End

Will this agency provide audio/visual equipment? *

Yes
No
N/A

Is translation needed? *

Yes
No

Is translation needed? What Language *

Training location

(Location name, complete street address) -- Leave blank if not applicable.

Virtual Request *

Yes
No

Virtual Platform *

WebEx, Zoom, MS Teams, etc...

Pre-recorded Session *

Yes
No

Requested Session length *

Additional Comments

Leave blank if no additional comments

Requester Signature *

Date *