Wednesday, August 20, Thursday, August 21 Wednesday, August 27, Thursday, August 28



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Dear Applicant,


Thank you for your interest in becoming a leader for the SW Regional Arthritis Center (SWRAC). The Chronic Disease Self-Management Leader Training Information is below.

Wednesday, August 20, Thursday, August 21

Wednesday, August 27, Thursday, August 28

(You must attend all four days)

8:30 AM-4:00 PM all days

Mercy Surgery Center, room 4 B, Springfield, Missouri

You must pre-register for the workshop by completing the enclosed Instructor Application and Leader Agreement. Please read the qualifications/pre-requisites for the leader training prior to submitting an application. If you have any questions or concerns about the enclosed forms, please contact Heather Scott at 417-888-6787.


Once your application is received you will receive a confirmation if you have been approved to attend the workshop. The training is limited to 15 people so early registration is encouraged. There will be no walk-ins allowed at the training.
Breakfast, lunch and snacks will be provided. There is no charge for the training.

Chronic Disease Self-Management Program

Leader Application

Name: Date:

Home Mailing Address:

Name of Employer and Mailing Address (if applicable): ___ ___________________________________

Home Phone: ____________Work Phone: ____________Cell Phone: ____________

E-mail Address:

Preferred contact address: Home Work

How did you hear about the Chronic Disease Self-Management Program?


Health Information

Do you have a chronic disease? Yes No

Does a family member or significant other have a chronic disease? Yes No
Have you taken the Chronic Disease Self-Management Program Yes No
workshop in the past?

If so, when and where?


Experience

Occupation/profession, present or past:

If currently employed, list position: Will leading the workshop be part of your employment duties? Yes No
If you have experience working with people with chronic conditions (diabetes, heart disease, respiratory problems, people with disabilities), describe your experience: _____________

________________________________________________________________

Describe any teaching, public speaking or group leader experience: ___ ________

Describe any volunteer experience:



Program Related Questions

What are your reasons for wanting to participate in the Chronic Disease Self-Management Program Leader Training Workshop? ___________________________________________________

What characteristics do you have that you feel would make you a good leader? __________

________________________________________________________________

Where do you plan to teach?



Please send form back by fax, mail or email directly to:
Heather Scott, Supervisor

Mercy-Regional Arthritis Center

3231 S. National, Ste. 400

Springfield, MO 65807

Heather.scott2@mercy.net
Fax: 417-888-6786
Due to limited space available early registration is encouraged.
Chronic Disease Self-Management Program

Leader Agreement

I understand that I will be authorized to teach the Chronic Disease Self-Management Program workshops only after I have attended all four days of leader training. I agree to attend all four days of leader training.


The Chronic Disease Self-Management Program Leader Training is only open to those who meet certain qualifications and who have been prescreened and approved. All applicants must complete the application form and receive confirmation of their approval to attend the workshop. No walk-ins will be allowed into the training workshop.
I agree to co-facilitate one 6-week Chronic Disease Self-Management Program workshop within six months following leader training. It is highly suggested that dates and leaders are already in place for the workshop prior to attending the training. In order to keep my certification as a Chronic Disease Self-Management Program Leader I agree to teach one 6-week workshop annually.
I agree to observe at least one session of a Chronic Disease Self-Management Class before attending the training. Contact Heather Scott to coordinate.
I will co-lead with another trained Leader.
I understand that the Chronic Disease Self-Management program is heavily scripted and agree to teach in strict accordance with the program as written in the Stanford University’s CDSMP Leader Manual. Furthermore, I agree not to offer personal advice, health advice or medical advice.
I agree to ensure that workshops are held in facilities that are physically accessible to people with disabilities and have meeting rooms that are safe and comfortable. (SWRAC will assist in setting up workshops. However, leaders may set up workshops on their own, if they choose.)
I agree to partner with the Southwest Regional Arthritis Center for all workshops including but not limited to; submitting paperwork, allowing the RAC coordinator to observe a workshop, and submitting class information before a workshop is held.
I understand that guest speakers may not lead any part of the course.
I understand that as a Chronic Disease Self-Management leader, I am a volunteer and not an employee of SWRAC. I further understand there is no fee for training and there is no financial compensation for the four-day training.



Applicant’s Signature Date


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