Leader Training Leader Training Agreement and Application Self-Management Program Leader TrainingThank you for your interest in becoming a leader. Living a Healthy Life (CDSMP) trainings are four days in length, with all four days needing to be attended in order to successfully complete the training. Living a Healthy Life with Diabetes (DSMP) and Living a Healthy Life with Chronic Pain (CPSMP) are one-day cross trainings to the CDSMP; you must successfully complete the four-day CDSMP training before you can cross-train in DSMP and/or CPSMP. You will be contacted by our staff to further discuss your application and to confirm that you have been approved to attend a training workshop. No walk-ins will be allowed at any self-management program training.Which training are you applying to attend?* CDSMP Monday-Thursday, November 5-8, 2018, 9am-4:30pm daily at Mosaic Life Care in St. Joseph DSMP Cross-Training Friday, November 9, 2018, 9am-4:30pm at Mosaic Life Care in St. Joseph CDSMP Monday-Thursday, November 12-15, 2018, 9am-4pm at Washington University in St. Louis CDSMP Tuesdays and Wednesdays, December 4-5 and 11, 2018, 8:30am-5:00pm daily at the Northeast Regional Arthritis Center (A.T. Still University) in Kirksville DSMP Cross-Training Thursday, December 13, 2018, 9am-4:30pm at the Northeast Regional Arthritis Center (A.T. Still University) in Kirksville I would like to be put on a wait list for future trainings Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is this address your home or work address?*HomeWorkPrimary Phone Number*What type of number is your primary phone number?*HomeWorkCellAlternative Phone NumberWhat type of number is your alternative phone number?HomeWorkCellPreferred Email Address* ExperienceOccupation/Profession (past or present)*If you will offer self-management programs as part of your employment duties, list your employer name. If you will not, type "Volunteer".*If you have experience working with people with chronic conditions (e.g., arthritis, diabetes, heart disease, respiratory problems, people with disabilities), describe your experience.*Describe any teaching, public speaking, or group leader experience.*Have you observed or participated in a CDSMP, DSMP, and/or CPSMP six-week workshop?*YesNoAre you a CDSMP Leader currently, or have you been one in the past?*YesNoClick here to review the terms of the Missouri Self-Management Program Leader AgreementI agree to all terms listed in the Missouri Self-Management Program Leader Agreement.*Type your full name and today's date This iframe contains the logic required to handle Ajax powered Gravity Forms.