Become a TakeCHARGE Ambassador and Learn to be a TakeCHARGE: 5 Step to Safer Health Care Facilitator.
Do you want to learn to become a TakeCHARGE: 5 Steps to Safer Health Care Ambassador and facilitate presentations in your community?  Training is approximately three hours and you must be committed to sharing what you learn with others.  To be notified when the next training will take place, complete this form and someone will get back to you.
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Name 
City and State where you are located.
Email
Phone number 
Cell phone
Do you have personal experience with patient safety / or medical errors?  If so, please share no more than two sentences / 50 words.
If there is one of the 5 Steps that you are particularly interested in, please explain. (See www.takecharge.care for a list of the 5 Steps.)
Tell us a little bit about yourself (no more than 50 words)
There is a small fee of $45 to participate in the training.  Are you able to pay that amount?
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