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* 1. Personal Information:

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* 2. Do you have diabetes? If yes, specify in the space provided.

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* 3. Do you care for someone with diabetes? Such as a spouse, family member etc

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* 4. Have you ever taken the PEP Talk- Diabetes, Healthy Feet and You workshop as a participant? If yes, please specify date and location:

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* 5. Languages other than English that you are able to lead workshops in:

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* 6. Leader Agreement:

Trainee Leaders Must  

1.Attend 1 day training in order to be able to deliver workshops.

2.Deliver the workshop only as outlined in the PEP Talk Leader manual.

3.Commit to delivering two workshops per year for the Central West Self-Management Program

Workshop leaders are not employees of the Central West Self-Management Program. An honorarium is provided following delivery of a 6 week workshop. Leaders must deliver the workshop only as outlined in the course manual.

I agree to deliver two Self-Management Workshops within 6 months after completing training and two workshops per year thereafter. I will deliver workshops in strict accordance with the course as written in the Leaders Manual, and as taught at leaders training. I will attend all four days of leader training.

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* 7. In order to complete this application, please submit a police Volunteer Record Search (Vulnerable Persons).


Police record check information:

Records Search Unit7750 Hurontario Street

Brampton, Ontario

L6V 3W6

Records Search Unit – Contact & Automated Information(905) 453-2121 ext. 4390e-mail:

Business Hours

Monday through Friday8:00 a.m. to 6:00 p.m.Saturday10:00 a.m. to 2:00 p.m.

Closed on statutory holidays


Individuals living outside of Peel need to contact their community’s Police Services for a criminal records check.