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Group Leader Application and Training Registration

​Group Leader Application/Training Registration

 

Name *

Organization

Street Address *

City *

State *

Zip Code *

County *

Preferred Contact Phone Number *

Email Address *

Gender

Race

Ethnicity

Highest Level of Education Completed *

What type of health 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 commitment to lead one 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 affiliated with an organization? If so, please provide.

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

Location(s) of Chronic Pain Leader Training

Date(s) of Chronic Pain Leader Training

Attachments

 


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