2023 PTC Leader Training Registration

Powerful Tools for Caregivers New Leader Training

Registration form
Training Information
- Dates and Times: June 5-9, 2023
- Location: Zoom
- Cost:
  - FCNN Affiliates: Free *
  - Minnesota Providers: $200 *
  - Providers Outside of Minnesota: $400
- Facilitated by:
  - Jess Drecktrah, MHA, MN, RN, faith community nurse
  - Lynn Amon, MSW, LSW
*Pending Application. This is possible thanks to funding from the State of Minnesota Board of Aging. To honor this investment, trainees who receive this subsidized rate must lead 2 workshops within the first year after training.
Contact Information
Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone number*
E-mail Address*
Organization Information
Name of Organization/Faith Community*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Organization/Faith Community *
Program Requirements
Please tell us why you want to be a Powerful Tools for Caregivers Leader:*
Describe your experience or qualifications in facilitating groups and working with older adults:*
Describe your plans for your first PTC workshop (dates, host site, city, participants, etc.):*
Describe your plans to facilitate at least one class each year.*
Please indicate whether you will lead workshops in partnership with FCNN or if you will be working with another provider organization.*

I will lead workshops with FCNNI will lead workshops with another provider organization. Please type the name of the provider organization below.
Provider organization (if not leading workshops with FCNN)
By signing my name below, I am agreeing to the specific responsibilities involved in becoming a Powerful Tools for Caregivers Leader with the Faith Community Nurse Network of the Greater Twin Cities.

I agree to:
1. Attend the full training;
2. Schedule my first PTC workshop within two months of the Leader training;
3. Lead two workshops in the first year after training;
4. Hold one workshop annually thereafter to maintain Leader certification;
5. Agree to complete all required workshop documentation;
6. Follow the script and format of the program and not offer personal or medical advice;
7. Provide up-to-date contact information to the Faith Community Nurse Network
Please sign here to indicate that you agree and will comply*
Payment will be charged once your application has been approved. Once your application is processed, you will receive a link to submit payment by credit card or you may pay by check. Payment must be received prior to the first day of training. The cost of registration includes a training manual, meals, and all materials.

For more information, contact Jessica Drecktrah, Chief Nursing Officer at jessica@fcnntc.org or 612-237-4639.
Should be Empty:

Powerful Tools for Caregivers New Leader Training