Living Well With Chronic Conditions

(Stanford Chronic Disease Self-Management Program)

REGISTRATION FORM FOR LEADER TRAINING

March 23, 24, 30, 31 - 9:00am - 4:00pm

People’s Energy Cooperative 1775 Lake Shady Avenue South, Oronoco, MN
(Take county road 12 exit off Hwy 52)

Registration Deadline: February 22, 2017

 
Name *
Name
Address *
Address
Phone *
Phone
Please check one *
Mileage reimbursement is available for those in the 11-county SE MN region (see map) for travel over 30 miles from leader training location. If you wish to request mileage reimbursement, please list the location you will be traveling from: *
The Southeast Minnesota Area Agency on Aging (SEMAAA) holds the license from Stanford University for the classes you will be leading and you will be reporting your class information to SEMAAA.
Leader Agreement
You cannot teach the course until you have attended all four days of the training. You will not be a “certified” leader until you have taught a complete class series. You must teach a complete class series within one year of receiving your initial training. Please notify the SEMAAA CDSMP Coordinator Lori Christiansen with your class dates prior to holding classes.
I agree to teach one entire Self-Management Course within 12 months. I will teach in strict accordance with the course as written in the Leaders Manual, and as taught to me at the leader training. I will attend all four days of the leaders training. I will notify Lori Christiansen at SEMAAA prior to holding classes.
Date *
Date
Please confirm that you are a real person *