Education Request Form - Elder Abuse Prevention Ontario

Section A: Contact Information

Name

First Last

Title

Name of Organization/Senior Group:

Street Address

City

Province

Postal Code

Email(Required)

Phone

Website

Have you previously requested/received an education session from EAPO?

Yes

Unsure

Section B: Audience

Please indicate the primary participants who will be attending the session: (check all that apply)

Please indicate the preferred language for presentation

English

French

Please identify the setting of the session. Note: EAPO's education sessions are being provided virtually on-line.

Phone-in Session (i.e. Seniors Without Walls)

Recreation Program

Senior's Fair

Membership/Association Meeting

Committee Meeting

Guest Speaker at Conference/Workshop Forum

Other

Please check the sector(s) who is the target audience"

Other, please specify:

Section C: Education Topics/Issues

EAPO provides education of a range of issues pertaining to elder abuse, to increase knowledge and awareness to recognize and prevent the abuse of adults. Please check the topics you would like covered in your educational session. If more than one topic is chosen, EAPO can arrange to create an ‘Educational Series’ for your participants. EAPO will work with you to arrange the appropriate presentation and time frames to cover the topics.

Please check the topics you would like included in the education session(s):

Other, please specify:

Please indicate other topics, if applicable:

Provincial Educational Programs

Beyond the general elder abuse education topics, EAPO also offers unique educational programs that are designed and delivered through a specific approach. Sessions can be structured to be only focus on One issue or a Series of sessions to cover a range of issues.

It's Not Right Neighbours, Friends and Family for Older Adults (INR)

INR uses a bystander approach and draws from the domestic violence intervention model of Recognize – Respond – Refer. INR teaches everyone across all sectors of society to recognize warning signs, builds skill to respond safely and effectively and to know where to refer for services and support. The INR program includes video case scenarios to illustrate various forms of elder abuse and interactive discussions. Please indicate your INR engagement preference(s).

Please indicate your preference on the issue(s) listed below:

Elder Abuse

Ageism & Senior’s Rights

Financial Abuse

Emotional Abuse

Intimate Partner Abuse

Tea & Talk Worskhops

Tea and Talk is meant to inspire seniors' groups, communities and supporting agencies, to host these workshops to engage older adults’ in starting conversations towards maintaining and creating healthy relationships. The workshop series includes eight short sessions on a variety of topics pertaining to elder abuse prevention and promoting the well-being of older adults. Each session includes interactive activities to engage participants and start conversations.

Please choose from the Tea & Talk Workshop Topics listed below:

Elder Abuse

Protecting your Finances

Ageism /Senior's Rights

Dating as an Older Adult

Sexual Harm in Older Adults

Increasing Self-Esteem

Caregiving Communications for Healthy Relationships

Delivery of Training

EAPO is currently providing virtual online sessions. In some circumstances, there may be the capacity and availability to provide in-person sessions. Please discuss this option when confirming your booking with EAPO staff.

Section D: Schedule (Date/Time)

Please indicate your preference on the length of educational session.

Number of Sessions

Please indicate three (3) preferred dates and times for the session(s).

Date - Option 1(Required)

Time(Required)

Time- Option 2

Time

Date - Option 3

Time

Location of Event(Required)

Street Address Address Line 2 City ZIP / Postal Code

Section E: Evaluation

All presentation sessions include an evaluation process, to assist EAPO in building quality sessions for community stakeholders and partners. An evaluation will follow each presentation and will be conducted in the most expeditious format (survey monkey/emailed summary) and be returned to EAPO within a week after the session.

Do you agree to engage your participants in completing an evaluation form after the session?

Yes

If not, please explain:

Section E: Administration

EAPO may opt to charge participants a modest fee to cover incidentals and staff time for preparation and delivery of training. An invoice will be sent prior to the session, with settlement of the account to be paid prior to the presentation.

Non-Profit Fee: Honorarium to cover any speaker costs.

For Education provided to For-Profit agencies and organizations, applicable fees may apply:

$150 for 1 hour

$400 for ½ day

Additional Notes/Comments/Questions or Feedback:

Date Request Submitted

Signature (First /Last Name)