Tai Ji Quan: Moving for Better Balance Interest Application

CONTACT INFORMATION

Name of Person Completing Form*

First NameLast Name

Organization or Site Affilation

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

APPLICATION

Complete Section 1: If you are an organization applying for funding and licensing.

Complete Section 2: To register instructors for training.

Complete Section 3: To explore collaboration opportunities if you are already offering/delivering Tai Ji Quan: Moving for Better Balance as a site or an instructor, but aren't under the multi-site license of Connecticut Community Care (CCC).

1. FUNDING OPPORTUNITIES FOR ELIGIBLE ORGANIZATIONS

Is your organization interested in funding to deliver a TJQ:MBB program?

Yes (if so, please complete Questions a through e.)No

a. Will you be delivering this program in person or virtually?

In PersonVirtually

b. Do you have a trained TJQ:MBB instructor who is an employee or on contract?

YesNoNot Sure

c. Do you have a TJQ:MBB instructor candidate who is an employee or on contract that will be attending New Instructor Training on September 17th & 18th, 2025?

YesNoNot ApplicableNot Sure

d. Do you anticipate barriers to recruiting participants or starting the TJQ:MBB program on or before the week of January 12, 2026?

e. Please tell us about the target demographic you aim to recruit as participants. .

f. As a sub-licensee of Connecticut Community Care, do you agree to:*

Use marketing and recruitment materials provided or approved by CCC?Complete and submit in a timely fashion, all required enrollment and evaluation data collection?Maintain accurate attendance records?Complete and adhere to a coordination agreement with the CCC?

Applications are open until August 8, 2025 and organizations will be informed of funding no later than August 29, 2025. Workshops must start no later than the week of January 12, 2026.

2. TRAINING FOR NEW AND CURRENT INSTRUCTORS AND IMPLEMENTATION ORGANIZATIONS

Please list individuals participating in training. Individuals interested in training should have experience as an exercise instructor, physical therapist or Tai Chi instructor. The Implementation Training is for site directors/program coordinators and the instructor. All training is virtual from 8 am - 4 pm on each date.

Participant #1

First NameLast Name

Email for Participant #1

example@example.com

Please indicate which training sessions Participant #1 will attend:

New Instructor Training: September 17th & 18, 2025Implementation Training: October 15, 2025Enhanced/Refresher Training: October 22, 2025

Participant #2

First NameLast Name

Email for Participant #2

example@example.com

Please indicate which training sessions Participant #2 will attend:

New Instructor Training: September 17 & 18, 2025Implementation Training: October 15, 2025Enhanced/Refresher Training: October 22, 2025

Participant #3

First NameLast Name

Email for Participant #3

example@example.com

Please indicate which training sessions Participant #3 will attend:

New Instructor Training: September 17 & 18, 2025Implementation Training: October 15, 2025Enhanced/Refresher Training: October 22, 2025

Participant #4

First NameLast Name

Email for Participant #4

example@example.com

Please indicate which training sessions Participant #4 will attend:

New Instructor Training: September 17 & 18, 2025Implementation Training: October 15, 2025Enhanced/Refresher Training: October 22, 2025

Register here for training (the CT Healthy Living Collective will contact you with additional details. Click the + button to add additional names.

3. AUTHORITY TO DELIVER THE TJQ:MBB PROGRAM

Check here if you are an organization or instructor delivering the TJQ:MBB program but unsure if you are operating under a required license and we will contact you to explore collaboration opportunities.

Please contact me.

Questions/Comments

Once submitted, your application will be reviewed. Remember:

Sites may be approved for funding and must sign and adhere to a coordination agreement with CCC. The funding is for $2,880 payable to the site and includes instructor training, instructor materials, promo materials and technical assistance.

Sites not approved for funding will still be able to deliver Tai Ji Quan: Moving for Better Balance under CCC's multi-site license. Sites must sign and adhere to a coordination agreement with the CCC. Instructor training and materials are included as are promo materials and technical assistance.

Only instructors affiliated with sites who complete and adhere to the coordination agreement with CCC are eligible to attend training and receive training materials.