AMOB Program Engagement Agreement

Program Engagement Agreement

A Matter of Balance Program
Part 1 of the two-part Program Engagement process.

The purpose of this Program Engagement Agreement is to provide clear expectations for the host organization (named here) in implementing the evidence-based A Matter of Balance (AMOB) program within the host organization's community - as part of the grant awarded to the Northern Virginia Falls Prevention Alliance.

This form is to be completed by the Primary Point of Contact of the Host Organization.
HOST ORGANIZATION
Organization's Name:*
Organization hosting the AMOB Program
Organization Type:*

EducationalFaith-basedHealth CareGovernmentRecreationalResidentialOther
Organization Size:*

0 - 5051 - 100101 - 250251 - 500500+
PRIMARY CONTACT:*

First NameLast Name
Primary Contact's Role at Organization:*
Primary Contact's Email Address:*
Primary Contact's Phone Number:*
Exercise programs currently offered by host organization:*
PROGRAM IMPLEMENTATION SITE
Program Site's Name:*
Location the AMOB Program will be held
Site Type:*

EducationalFaith-basedHealth CareGovernmentRecreationalResidentialOther
Site Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PROGRAM SCHEDULING
START Date (first class):*

MonthDayYear
Date
END Date (last class):*

MonthDayYear
Date
Weekly Schedule:*
(Example: Mon & Wed, 10am - 11am)
What is the registration process for this program?*
If not yet decided - insert TBD
Is this program open to the public?*
If only open to organization members - please specify
Is there a COST to take this program?*
If YES - please include the amount
PROGRAM COACHES

PLEASE NOTE: Two coaches are required to lead this program
AMOB Coach's Full Name:*
Proposed Training Date

MonthDayYear
If already trained, please inset date
AMOB Coach's Full Name:*
Proposed Training Date

MonthDayYear
If already trained, please insert date
Are program coaches part of the host organization?*
If not part of the host organization - what organization(s) (if any) are they affiliated with?
Part 2 of this A Matter of Balance Engagement process consists of:

(A) Supplies/equipment provided by the grant for the program at this site

(B) Expected implementation process dates and timelines.

After submitting this form, we will get in touch with you for next steps.

Thank you for completing this A Matter of Balance Program Engagement Agreement!
Should be Empty:

Program Engagement Agreement

HOST ORGANIZATION

PROGRAM IMPLEMENTATION SITE

PROGRAM SCHEDULING

PROGRAM COACHES