Chronic Disease Self-Management Program (CDSMP) or
"Living Well with Chronic Conditions" Leader Training
March 2017

Registration form for Leader Training

March 13, 14 & March 20, 21, 2017
9:00 a.m. to 5:00 p.m.

Redwood Area Community Center
Conference Center 3A
901 Cook Street
Redwood Falls, MN 56283

Registration is due with payment by Friday, March 3, 2017.
The cost of the training is $125 (this includes lunch and refreshments).

You can either pay by Paypal or check.

You can pay with PayPal on the "Become a Leader" tab on this page.

Checks can be made out to MNRAAA and mailed to:

Kelly Wolle
Minnesota River Area Agency on Aging
201 N. Broad St., Suite 102
Mankato, MN 56001

Question Title

* 1. Leader's Contact Information

Name *

Company

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Email Address *

Phone Number *

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* 2. Would you like to sign up to receive the latest news from MNRAAA via email?

Yes

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* 3. Do you require any special accommodations?

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* 4. Please identify individual(s) you will be working/coordinating with to offer workshops.

Please Note: All classes require two trained leaders. Leaders must attend both days of training if you don’t already have a certified co-facilitator.

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* 5. Sponsoring Organization:

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* 6. Please identify the communities where you plan to implement CDSMP Class:

Leader agreement: You cannot teach the course until you have attended all four days of the training. You must teach a complete class series within 6 months of receiving your initial training. Please notify the MNRAAA office with your class dates prior to holding classes.

I agree to teach one entire CDSMP/Living Well with Chronic Conditions course within 6 months. I will teach in strict accordance with the course as written in the Leaders Manual, and as taught to me at leaders training. I will attend all four days of the leaders training. I will notify MNRAAA prior to holding classes.

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* 7. (By entering your name in the box below, you agree to the terms of the leader agreement.)

For more information, contact:

Kelly Wolle
Administrative and Communications Assistant
Minnesota River Area Agency on Aging
201 N. Broad St., Suite 102
Mankato, MN 56001

kwolle@mnraaa.org
507.387.1256 x102
Fax: 507.387.6223

Question Title

* 1. Leader's Contact Information

Question Title

* 2. Would you like to sign up to receive the latest news from MNRAAA via email?

Question Title

* 3. Do you require any special accommodations?

Question Title

* 4. Please identify individual(s) you will be working/coordinating with to offer workshops.Please Note: All classes require two trained leaders. Leaders must attend both days of training if you don’t already have a certified co-facilitator.

Question Title

* 5. Sponsoring Organization:

Question Title

* 6. Please identify the communities where you plan to implement CDSMP Class:

Question Title

* 7. (By entering your name in the box below, you agree to the terms of the leader agreement.)

* 4. Please identify individual(s) you will be working/coordinating with to offer workshops.

Please Note: All classes require two trained leaders. Leaders must attend both days of training if you don’t already have a certified co-facilitator.