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Group Leader Application and Training Registration
Find A Workshop
Great Plains Quality Innovation Network
Group Leader Application/Training Registration
Please provide both first and last name
Please provide your street address so we may communicate with you and ensure our records are complete.
Residence Zip Code
Preferred Contact Phone Number
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
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