Move More, Feel Better Event Request Form (July-October, 2016)

Please complete this form prior to requesting onsite wellness events at your department. Questions about completion of this form may be directed to HSS Wellness Team. Please send all completed forms to .

Move More / Find Your 30 / Feel Better
HSS Wellness & EAP Seminars
Events must be requested at least 4 weeks in advance. / ·  Move More, Feel Better
·  Move at Work / ·  Move More, Feel Better
·  Making Work Work: 4-part series including these four seminars:
·  Stress Management
·  Anger Management
·  Conflict Resolution
·  Managing Emotions
KP Seminars
Events must be requested at least 6-8 weeks in advance. / ·  Healthy Habits
·  Your Strong and Healthy Back
·  Get Moving
·  Why Eat Breakfast? / ·  Healthy Weight: Setting Yourself Up for Success
·  Understanding Your Metabolism / ·  Healthy Mind, Healthy Body: Managing Stress
·  Getting Healthy Sleep
·  T’ai Chi Chih: Joy Through Movement
·  Qi Gong
AHA Seminars
Events must be requested at least 4 weeks in advance and have a minimum of 25 people. / ·  Motivation to Get Moving / ·  Walk to Boost Your Metabolism
·  Which Diet is Best?
·  Cooking Demonstration: Easy & Healthy Meals / ·  Mindfulness for Stress Reduction
·  Hands Only CPR
Coaching
Events must be requested at least 6-8 weeks in advance. / ·  Move More Coaching day or series / ·  Find Your 30 Coaching day or series / ·  Feel Better Coaching day or series

SECTION 2: EVENT DETAILS Please complete the below for awareness and program activities. Answer all questions in the gray shaded field in the events table below.

Requester Information / Event 1 / Event 2 / Event 3
Name
Email
Phone Number
Event Partnership Details
Are you currently partnering with other Wellness Champions for your event?
Please list name(s) of partnering Champions
Event Specifics
Event Name
Event Provided (Wellness, EAP, KP, AHA)
Requesting Department Name
Expected Participation
Preferred Date(s) and Time(s) (1st Choice)
(Please include start and end time. If requesting a series please include all dates and times the series will take place)
Alternate Date and Time (2nd Choice)
(Please include start and end time. If requesting a series please include all dates and times the series will take place)
Address, City, State, Zip
Room and Room Location
(i.e. Conference Room A, 2nd floor)
Indoor or Outdoor Location?
Room Details
(capacity/private room/shared space)
Parking (Please describe where our staff can park)
Available Technology
Which of the following are in the room or can be provided by the onsite contact? (Computer, projector, internet access, power source, extension cord, audio, etc.)
Day-of Event Contact
Enter “same” if same as requestor information
Name
Email
Phone Number
(Include cell phone where available)
Scheduling Tool
KP Events only: Which scheduling tools will you use for sign up’s (Online schedule tool or paper)?