8/2/2019 Chicago Class Leader Registration Form CDSMP-DSMP

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Take Charge of Your Health ProgramsClass Leader Training

Provided by Rush University Medical Center

Thank you for your interest in becoming a class leader of Take Charge of Your Health programs. Pleasecomplete the following registration form and return to Dana Bright at Rush University Medical Center, 312-

942-6116 (fax) or Dana_M_Bright@rush.edu.

This program follows the Chronic Disease Self-Management Program model as created by Stanford

University. Research has demonstrated the effectiveness of the program in improving the health of

participants over time. Funding for this program is made possible by a grant from the Illinois Department ofPublic Health.

Name:

Title/Position: (if applicable):

Organization (if applicable):

Work/Home Address:

City: State: Zip:

Phone: Fax:

E-mail:

The following questions will help us support you during the time you lead workshops.

1. I am interested in being a class leader for the following program(s): (check all that apply)

____ Take Charge of Your Health ____ Tomando Control de su Salud (Spanish version)

____ Take Charge of Your Diabetes ____ Tomando Control de su Diabetes (Spanish version)

2. This program focuses on ongoing health conditions. Could you share briefly your experience with

chronic illness, either personally or professionally?

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

3. Class leaders are asked to lead a minimum of two workshops in a calendar year. Do you have apreference on the days or times you would like to lead workshops?

8/2/2019 Chicago Class Leader Registration Form CDSMP-DSMP

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__________________________________________________________________________

4. Are you proficient (bilingual) in a language other than English? If so, please list the language.

__________________________________________________________________________

5. Are there any special physical accommodations you need made in order to lead workshops?

_________________________________________________________________________

6. Do you have any experience facilitating groups and/or working with older adults?

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

7. Is there anything else you would like to add about what you can bring to Take Charge of Your Healthprograms?

__________________________________________________________________________

__________________________________________________________________________

8. Workshop host sites are located throughout the City of Chicago. Please indicate in what geographical

area you would like to lead (circle all those that apply):

Downtown Chicago Far Westside

Near Southside Near NorthsideFar Southside Far Northside

Near Westside

9. If you would also be interested in leading in suburban Cook County, please indicate the area(s).(circle all those that apply)

Southern Townships Western Townships Northern Townships

Bloom Berywn Barrington

Bremen Cicero Elk Grove

Calumet Leyden EvanstonLemont Lyons Hanover

Orland Norwood Park New Trier

Palos Oak Park Niles

Rich Proviso NorthfieldStickney River Forest Palatine

Thornton Riverside Schaumburg

Worth WheelingMaine

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