CDSME Workshop Registration
Chronic Disease Self-Management Education (CDSME) Workshops
WHICH WORKSHOP ARE YOU REGISTERING FOR? ALL WORKSHOPS ARE HELD AT MILFORD WELLNESS VILLAGE.
*
Tuesdays, May 19-June 23, 5:30-8pm
Thursdays, May 19-June 23, 9-1130 am
Thursdays, June 4-July 9, 530-8pm
Participant Information:
If you are completing this form for another person, PLEASE PROVIDE ADDTIONAL INFO BELOW BEFORE FINALIZING REGISTRATION.
Name of Registrant
First Name
Last Name
Date of Birth:
/
Month
/
Day
Year
DOB: MO / DA / YR
Gender:
Please Select
Female
Male
Prefer Not To Say
Phone Number
-
Area Code
Phone Number
Email
example@example.com
We will contact you to provide Workshop details, and directions. Just hit the REGISTER button!
Mark your Calendar!
Register
Referral Information:
If you referred the above individual to this Workshop, please provide additional information below.
Referrer Name
First Name
Last Name
Referrer Organization:
Email
example@example.com
Patient Consent:
Check this box if client has been informed of referral.
Reason For Referral (check all that apply)
Client has chronic condition(s) and is seeking assistance
Client Seeking lifestyle change resource
Client would benefit by Peer support/socialization
Other
Would referrer like a 6-week follow up report?
Please Select
Yes
No
Should be Empty: