Cultural Competency Renewal Course Registration Form

smiling caregiver and elderly woman hugging

Facility Name:(Required)

Your Name:(Required)

First Last

Email:(Required)

Phone:(Required)

Has your facility paid the facility initial registration fee in 2022?(Required)

Yes

If your facility has taken the initial course from another provider but would like to take this renewal course, you will need to pay the facility initial registration fee.

Type of facility(Required)

Skilled Nursing Facility

Assisted Living (RFG)

Facility initial registration fee: Skilled Nursing Facility (Member)

Price:

Facility initial registration fee: Skilled Nursing Facility (Non-member)

Price:

Facility initial registration fee: Assisted Living Facility (Member)

Price:

Facility initial registration fee: Assisted Living Facility (Non-member)

Price:

Renewal Course registration fee: Skilled Nursing Facility (Member)(Required)

Renewal Course registration fee: Skilled Nursing Facility (Non-member)(Required)

Renewal Course registration fee: Assisted Living (Member)(Required)

Renewal Course registration fee: Assisted Living (Non-member)(Required)

Facility Coordinator

We will use the contact information below as the central point-of-contact for your facility’s employee registrations. The facility coordinator sends registration links to employees that take the training. The coordinator also ensures the employees complete the necessary paperwork post-training to receive a training certificate.

Facilty Coordinator's Name:(Required)

First Last

Name of Facility:(Required)

Email:(Required)

Phone:(Required)

TOTAL REGISTRATION FEE

Payment:(Required)

Invoice

Credit Card

Payment:(Required)

Credit Card

STOP BEFORE YOU CLICK "SUBMIT"

Note - If you plan to pay by credit card, please make note of the “total registration fee” above before clicking "SUBMIT"

Address to Mail Invoice:(Required)

Street Address Address Line 2 City State ZIP Code

Pay with Credit Card*

American Express

MasterCard

Visa

Supported Credit Cards: American Express, MasterCard, Visa

Card Number Expiration Date Security Code Cardholder Name

Upcoming Events

Apr 28Cultural Competency Training
May 19Cultural Competency Training
Jun 30Cultural Competency Training

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Facility Members

To join our association, please complete the online application or download and complete our pdf application. Once your information is received, we will follow up with you to complete the application process. Click the link below to get started.

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