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Group Leader Application

​Group Leader Application/Training Registration

Click here to register for training or to become a group leader.

 
Name (First & Last) *
Organization (if applicable)
Address, City, State, Zip, County
Preferred Contact Phone Number
Email Address *
Gender
Please identify your race (optional)
Please Identify your Ethnicity
Highest Level of Education Completed
What type of insurance do you have?
Please select one
Optional, if you have a chronic condition, please list.
How confident are you that you will make and keep the committement to lead one (1) workshop series per year?
How comfortable are you speaking in a public group or situation?
How many miles are you willing to travel each week, one-way, to lead a workshop series?
Are you affliated with an organization? If so, please list.
Why do you want to become a Group Leader?
Location(s) of Chronic Disease Leader Training
Date(s) of Chronic Disease Leader Training
Location(s) of Diabetes Leader Training
Date(s) of Diabetes Leader Training
 


This material was prepared by the Great Plains Quality Innovation Network, the Medicare Quality Improvement Organization for Kansas, Nebraska, North Dakota and South Dakota, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 11SOW-GPQIN-KS-GEN-08/0914