Living Well with Chronic Pain or
Chronic Pain Self-Management Program (CPSMP) Leader Cross-Training
May 2-3, 2020

Registration form for Leader Training

May 2 & 3, 2020
9:00 a.m. to 5:00 p.m.

Sanford Worthington Medical Center

1018 6th Ave.

Worthington, MN 56187

Registration is due with payment by April 24, 2020.
The cost of the training is $120 (this includes lunch and refreshments).

Scholarships may be available upon request.

You can either pay by Paypal or check.
You can pay with PayPal at the bottom of this page.

Checks can be made out to MNRAAA and mailed to:
Minnesota River Area Agency on Aging
201 N. Broad St., Suite 102
Mankato, MN 56001

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* 1. Leader's Contact Information

Name *

Organization

Mailing Address *

City/Town *

State *

ZIP *

Email Address *

Phone Number *

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* 2. Have you completed CDSMP/Living with Chronic Conditions leader training?

Yes

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* 3. What was/is the start date of the most recent CDSMP/Living with Chronic Conditions class you lead?

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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 CPSMP Class:

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* 7. Do you require any special accommodations?

Leader agreement: You cannot teach the course until you have attended both days of the cross-training. You must teach a complete class series within 12 months of receiving your initial training. You will need to register your class on yourjuniper.org prior to hold classes.

I agree to teach one entire CPSMP/Living Well with Chronic Pain course within 12 months. I will teach in strict accordance with the course as written in the Leader Manual, and as taught to me at leader training. I will attend both days of the leader cross-training. I will notify MNRAAA prior to holding classes.

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* 8. Check the box for the emails that you like to receive from MNRAAA.

I would like to receive Program Development emails (including future leader meetings and leader training opportunities).

I would like to receive MNRAAA Newsletter emails.

I would like to receive both Program Development emails and MNRAAA Newsletters.

I do not wish to sign up to receive emails.

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

For more information, contact:

Erica Schott
Office Manager
Minnesota River Area Agency on Aging
201 N. Broad St., Suite 102
Mankato, MN 56001

eschott@mnraaa.org
507.387.1256 x104
Fax: 507.387.6223

Question Title

* 1. Leader's Contact Information

Question Title

* 2. Have you completed CDSMP/Living with Chronic Conditions leader training?

Question Title

* 3. What was/is the start date of the most recent CDSMP/Living with Chronic Conditions class you lead?

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 CPSMP Class:

Question Title

* 7. Do you require any special accommodations?

Question Title

* 8. Check the box for the emails that you like to receive from MNRAAA.

Question Title

* 9. (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.