Oregon | WORKS Participation Form

Please fill out the following form to be considered as a Community Host for an Oregon | WORKS Community Internship Workshop. MEDP will be contacting the contact listed on the form within a week. If you would like more information about the Oregon | WORKS, please visit our webpage: www.mcminnvillebusiness.com/oregon-works

Participation forms must be filled out before April 21, 2017. Workshop dates need to be confirmed by May 5, 2017.

Organization:
Website:
First Name:
Last Name:
Title:
Address:
Email:
Phone (123-123-1234):
Cell (123-123-1234):
Your Regional Solutions Coordinator:
Email:
Cell (123-123-1234):
Tell us about your community
Tell us about internship programs currently happening in your community:
Who would you like to invite to attend the Oregon | WORKS Community Internship Workshop?
What would be the desired outcome from a community internship workshop?
Logistics Event checklist (must answer yes to the following):
Can you fill a room with 20 stakeholders, business leaders, and others?	Yes No
Do you have a location for 20 attendees?	Yes No
Does the location have AV and WiFi?	Yes No
Scheduling We are delivering a 6-hour training. Our agenda allows 30 minutes for a lunch break with two 10 minute breaks. Refreshments and meals are the responsibility of the host community.
What are your preferred training dates between June 1-16? (prioritize three dates)
June 1	[not a priority date] 1 2 3
June 2	[not a priority date] 1 2 3
June 5	[not a priority date] 1 2 3
June 6	[not a priority date] 1 2 3
June 7	[not a priority date] 1 2 3
June 12	[not a priority date] 1 2 3
June 13	[not a priority date] 1 2 3
June 15	[not a priority date] 1 2 3
June 16	[not a priority date] 1 2 3
Prioritize your choices for one of four 30 minute pre-workshop planning sessions:
May 8	1 2 3 4
May 9	1 2 3 4
May 15	1 2 3 4
May 17	1 2 3 4
Preferred Time	Morning Afternoon
Prioritize your choices for one of three 60-minute post-workshop coaching sessions:
June 19	1 2 3
June 20	1 2 3
June 26	1 2 3
Preferred Time	Morning Afternoon
Any additional information you would like to provide us with?:
The Oregon | WORKS Workshop was developed by MEDP with the support of an Oregon Talent Council grant and in partnership with Governor Brown's Regional Solutions office.