Region: (only the following regions are supported)
1 2 3 5 6 7 12

Name:

Date of Birth (mm/dd/yyyy):

Address:

City, State, Zip:

Home Phone:

Other Phone:

1. Do you have a chronic health condition? Yes No
2. Have you ever taken the Chronic Disease Self-Management Workshop? Yes No
   If yes, please note date and location:
3. Are you able to commit to co-leading one workshop (2 ½ hours once a week for six weeks) within six (6) months of completing the Lay Leader Training? Yes No
4. Are you able to commit to co-leading at least one workshops (2 ½ hours once a week for six weeks) each year to maintain certification and for a duration of at least two years? Yes No

Lay Leader Agreement:

You cannot teach the course until you have attended all four days of the Lay Leader Training.  Trainee leaders are required to make a commitment to teach at least two workshops in the State of Georgia.  Lay Leaders must teach the workshop only as outlined in the course manual.

I agree to the above, and I will teach in strict accordance with the course as written in the Leaders Manual, and as taught at leaders training.