Living Well With Chronic Conditions
In-Person Workshop Registration Form

Thank you for your interest in the Living Well with Chronic Conditions in-person, group workshops. We limit the number of participants per workshop, so we fill sessions on a first-come, first-served basis.

After registering, you will receive a confirmation letter, phone call, or e-mail a few weeks prior to the workshop. If the session is filled, you will be contacted about alternative dates or locations.

There is no cost for the workshop; however, we ask each person or family to pay what they can toward the cost of the workbook, $15. (Only one copy per family is needed.) Financial assistance is available on request.

Check the in-person workshop schedule and note the location, dates, and time of the series you would like to attend.


*Indicates a required field

*Workshop location:
*Workshop dates:
*First and last name:
Member ID #:
*E-mail:
*Address:
*City:
*State:
*ZIP code:
Daytime phone:
*Evening phone:
Age:
Gender:

Will you be attending with a spouse, family member, or friend? If so, fill out the information below for that person.

First and last name:
Member ID #:
E-mail:
Address:
City:
State:
ZIP code:
Daytime phone:
Evening phone:
Age:
Gender:

Optional: What ongoing health conditions do you have? (Check all that apply.)

Arthritis  
Asthma  
Congestive heart failure  
Coronary artery disease  
COPD  
Depression  
Diabetes  
Fibromyalgia  
High blood pressure  
Other:  

How did you hear about Living Well With Chronic Conditions? (Check all that apply.)

Northwest Health magazine  
Friend or family member  
Group Health Web site  
Other:
My doctor or health care team:
Name of doctor and medical center:

This form will be sent via e-mail, an unsecured means of communication. While Group Health takes careful measures to protect the privacy and confidentiality of any information you send us, we cannot absolutely guarantee secure transmission of your information from your computer to our servers. To register by phone, call the Resource Line at 206-326-2800 or 1-800-992-2279.