WELL Trainer Interest and Proposal Form

If you’re interested in proposing or leading a training course through our WELL program, please complete this form and a member of our team will reach out to you.

Contact Information

Name

Work Email Address

Phone Number

Affiliation with WCSU

Are you a Western Connecticut State University employee?

YesNo

Are you a Faculty and/or Staff member?

FacultyStaff

Department

Current Role/Title

Company / Organization

Department

Current Role/Title

Are you a WCSU Alumnus?

YesNo

Graduation Year and Degree(s) received

Training Proposal

Course Type (select all that apply)

CertificationMicro-CredentialSeminarNot Sure

Program Details

Program Training Title

Training program description - please give a general overview of the training and expected outcomes.

Target audience or learners served by the training

Trainer Qualifications

Briefly explain your qualifications:

Upload a PDF copy of your resume/CV

Please include any additional comments or information that would be helpful: