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 21-June 25, 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 Participant
First Name
Last Name
Date of Birth:
/
Month
/
Day
Year
DOB: MO / DA / YR
Gender:
Please Select
Female
Male
Prefer Not To Say
Participant Phone Number
-
Area Code
Phone Number
Participant Email
example@example.com
We will contact you to provide more information, and driving directions. Just hit the REGISTER button!
Mark your Calendar!
Register
Referrer Information:
If you referred the above individual to this Workshop, please provide additional information below.
Referrer Name
First Name
Last Name
Referrer Organization:
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
Patient Consent:
Check this box if client has been informed of referral.
Referrer Email
example@example.com
Would referrer like a 6-week follow up report?
Please Select
Yes
No
Should be Empty: