Dementia Beyond Drugs: Changing the Culture of Care Live Online Training in 2024! – 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).

Dementia Beyond Drugs Scholarship Application 2024

Nursing Home Scholarship Application

Nursing Home Information (Mark N/A if you are a LTCO surveyor or other non-affiliated nursing home stakeholder)

Nursing Home Address

Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code

Nursing Home Contact Person

Name

First Last

Email(Required)

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. Each participant MUST have their own unique and valid email address to access Zoom. If you will be accessing Zoom in a group setting, we still need individual email addresses for communication purposes.

Team Member 1

Name

First Last

Email

Enter Email Confirm Email

Phone

Job Title/Role

NAB Number (R plus 7 numbers - Required if NHA):

Team Member 2

Name

First Last

Email

Enter Email Confirm Email

Phone

Job Title/Role

NAB Number (R plus 7 numbers - Required if NHA):

Team Member 3

Name

First Last

Email

Enter Email Confirm Email

Phone

Job Title/Role

NAB Number (R plus 7 numbers - Required if NHA):

Team Member 4

Name

First Last

Email

Enter Email Confirm Email

Phone

Job Title/Role

NAB Number (R plus 7 numbers - Required if NHA):

Team Member 5

Name

First Last

Email

Enter Email Confirm Email

Phone

Job Title/Role

NAB Number (R plus 7 numbers - Required if NHA):

Team Member 6

Name

First Last

Email

Enter Email Confirm Email

Phone

Job Title/Role

NAB Number (R plus 7 numbers - Required if NHA):

OTHER NURSING HOME STAKEHOLDERS

Please provide information about affiliated nursing home stakeholders who will be participating from the same nursing center. All listed below must be aware of and acknowledge their participation in the training so they can save the dates. Please do not register anyone without their permission.

Georgia Long Term Care Ombudsman

Name

First Last

Email

Enter Email Confirm Email

Phone

Nursing Home Resident

Name

First Last

Email

Enter Email Confirm Email

Phone

Nursing Home Volunteer

Name

First Last

Email

Enter Email Confirm Email

Phone

Family Member of a Nursing Home Resident

Name

First Last

Email

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

MM slash DD slash YYYY

By clicking "Submit" below you agree for your email address to be added to our mailing list.

Save and Continue Later

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Please email your completed application to the attention of Crystal Williams:
Email: cwilliams259@gsu.edu

Culture Change Network of Georgia Mission
To change the way Georgians think and feel about aging and disability by creating the kind of care and support we want for our loved ones and ourselves.

TIADC Project Staff
Jennifer Craft Morgan: Director and Professor, Gerontology Institute, Georgia State University
Elisabeth O. Burgess: Associate Dean of Faculty Affairs and Professor, Gerontology Institute, Georgia State University
Crystal Warren Williams: Project Manager
Celeste Greene: Educational Media Specialist

Consultants
Walter Coffey: WD International Consulting
Kim McRae: Have a Good Life
Joan Carlson: JMC Consulting
Rose Marie Fagan: Founding/Former ED National Pioneer Network
Leigh-Anne Royster: Duke University
Cameron Camp: Center for Applied Research in Dementia

Culture Change Network of Georgia Steering Committee
Walter Coffey & Kim McRae: CCNG Co-Founders (WD International Consulting & Have a Good Life respectively)
Ginny Helms: LeadingAge Georgia
Pam Clayton: GHCA
Linda Kluge: Alliant Health Solutions
Jennifer Craft Morgan: Gerontology Institute GSU
Becky Kurtz: Atlanta Regional Commission
Rose Marie Fagan: Founding/Former ED National Pioneer Network
Sal Kibler: Georgia Tech Tools for Life Program

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