• Leader Training Registration Form

  • About

    Use this form to register or waitlist for Leader Training and/or Cross-Training in the following programs:

    • Chronic Disease Self-Management Program (CDSMP)
    • Diabetes Self-Management Program (DSMP) Cross-Training*
    • Chronic Pain Self-Management Program (CPSM) Cross-Training*
    • Cancer: Thriving & Surviving (CTS) Cross-Training*
    • Manejo Personal de la Diabetes Leader Cross-Training*
    • National Diabetes Prevention Program (National DPP)

    *CDSMP Leader Training must be completed before registering for any cross training.

    Instructions

    1. Complete all sections of this form.
    2. Click "Submit" to send us your application.
    3. Once your application is screened, will will send an organizational questionnaire to the contact you provide. Both forms must be completed and submitted before your registration can be approved.

    Ready to get started? Click "Next" to begin.

    If you have issues with this form or questions about Leader Training, please call 833-673-9355 or email health.promotion@nwsds.org.

  • Training Info

  • Will you be able to lead 1 workshop within 6 months of completing your training, and 2 workshops PER YEAR?

  • You must be able to lead 1 workshop within 6 months of completing your training, and 2 workshops per year. Please call 833-673-9355 or email health.promotion@nwsds.org if you have any questions.

  • Applicant Info

  • Format: (000) 000-0000.

  • Additional Info

  • Are you bilingual in English and Spanish? If so, do you intent to lead workshops in Spanish?
  • Are you a Lay Leader (non-health/social service professional)?
  • Are you living with chronic conditions?
  • Have you attended a Living Well program as a participant?
  • Accommodations Requested:

  • Organizational Contact

  • Once your application is screened, will will send an organizational questionnaire to the contact you provide. Both forms must be completed and submitted before your registration can be approved.

  • Format: (000) 000-0000.

  • Program Licensure

  • In order to participate in this training, you must be affiliated with an organization that is licensed by the Self Management Resource Center (SMRC) to deliver the selected Leader Training.

  • Please indicate your organization’s status below.
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  • For detailed information regarding program licensure, please click here or contact the Self Management Resource Center at 1-650-242-8040 Ext 406. Note that training cannot be provided to individuals who are not affiliated with a licensed organization.

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