Dementia Beyond Drugs: Changing the Culture of Care Live Online Training in 2023! - Application

Nursing Homes are required to register as a TEAM and include a Key Contact Person. If you are a Stakeholder, you do not have to register as a team and special directions for you are included. PLEASE TYPE YOUR APPLICATION (if possible).

Nursing Home Scholarship Application

Name of Nursing Home

Nursing Home Address

Street Address City State ZIP Code

Check N/A if you are a LTCO, surveyor or other non-affiliated nursing home stakeholder

Nursing Home Contact Person

Name

First Last

Enter Email Confirm Email

Phone

Job Title/Role

NAB Number (Required, if NHA):

NURSING HOME TEAM REGISTRATION

Please provide information about the 4-6 team members who will be participating from the same nursing center. Please remember the contact person can be listed as one of the participating team members, if appropriate. Please provide the email each participant will use to access zoom. If you will be accessing zoom in a group setting, please also provide individual email addresses for communication purposes.

Team Member 1

Name

First Last

Enter Email Confirm Email

Phone

Job Title/Role

NAB Number (Required, if NHA):

Team Member 2

Name

First Last

Enter Email Confirm Email

Phone

Job Title/Role

NAB Number (Required, if NHA):

Team Member 3

Name

First Last

Enter Email Confirm Email

Phone

Job Title/Role

NAB Number (Required, if NHA):

Team Member 4

Name

First Last

Enter Email Confirm Email

Phone

Job Title/Role

NAB Number (Required, if NHA):

Team Member 5

Name

First Last

Enter Email Confirm Email

Phone

Job Title/Role

NAB Number (Required, if NHA):

Team Member 6

Name

First Last

Enter Email Confirm Email

Phone

Job Title/Role

NAB Number (Required, if NHA):

OTHER NURSING HOME STAKEHOLDERS

Please provide information about affiliated nursing home stakeholders who will be participating from the same nursing center.

Georgia Long Term Care Ombudsman

Name

First Last

Enter Email Confirm Email

Phone

Nursing Home Resident

Name

First Last

Enter Email Confirm Email

Phone

Nursing Home Volunteer

Name

First Last

Enter Email Confirm Email

Phone

Family Member of a Nursing Home Resident

Name

First Last

Enter Email Confirm Email

Phone

Personal Statement

Why do you want you (or your nursing center) to attend the Dementia Beyond Drugs: Changing the Culture of Care training?

What do you think will be the benefit(s) to you (your nursing center) as a result of attending the Dementia Beyond Drugs: Changing the Culture of Care training?

How will you share what you learn (or your nursing center learns) at the Dementia Beyond Drugs: Changing the Culture of Care training and with whom will you (or your nursing center) share it?

CERTIFICATION STATEMENT

Signature

Date

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