Take Control of Your Health
Notification of Upcoming Peer Leader Training

Site Name

Training Dates

Start Time

Address

City

Zip Code

Host Organization

Language (if other than English)

Master Trainer 1

Telephone Number

Email Address

Master Trainer 2

Telephone Number

Email Address

Master Trainer 3

Telephone Number

Email Address

Program Type:

Chronic Disease Self-Management Program	Tomando Control De Su Salud

Diabetes Self-Management Program	Manejo Personal de la Diabetes

Cancer Thriving and Surviving Workshop
Would you like to have this workshop marketed through the state listserv? Yes No
If yes, please provide the contact information for registration:

Master trainers complete and return this form

when scheduling a peer leader training.

ACS-24	Send form to Andrew Biederman, NJDHS, via email at

FEB 19	andrew.biederman@dhs.state.nj.us; Fax: 609-588-7630

ACS-24, Notification of Upcoming Peer Leader Training

ACS-24, DAS, notification, upcoming training, peer leader, take control of your health,

Dennis McGowan

2016-09-16

Windows User

human services