Leader Training Registration Online Submission Form: Leader Training Registration Select program(s) for leader training* Select All Living a Healthy Life (CDSMP) Living a Healthy Life with Diabetes (DSMP) Living a Healthy Life with Chronic Pain (CPSMP) What type(s) of Leader Training are you providing?* Full four-day CDSMP One-day Cross-Training (DSMP or CPSMP) Update Training (to new program edition) Refresher Training (to leaders who need recertification) Who is the Coordinator for this training?* First Last Most often, this will be the RAC Coordinator or one of the Master Trainers Email for Training Coordinator* Phone number for Training Coordinator*Name of Location where training will be held* Location of Training* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Name of 1st Master Trainer* First Last Name of 2nd Master Trainer* First Last Names of additional Master Trainer(s) First Day of Training* Month Day Year Start Time of Training (for each day)* : Hours Minutes AM PM AM/PM End Time of Training (for each day)* : Hours Minutes AM PM AM/PM Second Day of Training Month Day Year Third Day of Training Month Day Year Fourth Day of Training Month Day Year Fifth Day of Training Month Day Year What is the maximum number of leader applicants this training will accept?*What is the cost for leader applicants to attend this training (per training participant)?* What email should leader applicants' registration forms go to?* May be RAC Coordinator, Training Coordinator, or one of the Master TrainersPlease enter any special instructions that you would like for leader applicants to receive after submitting the registration form or additional notes regarding your training.
