Where will you be tomorrow?• October 23-25, 2019 •

MI-NADONA/LTC ANNUAL CONVOCATION

Motor City Casino Hotel | Detroit, MI

welcomeThe theme for this year’s convocation is “Where Will You Be Tomorrow?” Nurse leaders in long-term care are constantly readjusting to changing clinical, regulatory, and reimbursement requirements. Learning how to refocus and redirect yourself is critical. The theme this year is designed to help you figure out your plan of attack for the future.

MI-NADONA/LTC MEMBERSHIP:If you are not already a member of NADONA/LTC, please be sure to visit www.MINADONA.org to sign-up for membership now to receive the discounted NADONA member registration rate and many other benefits or complete page 17 and fax to NADONA at (513) 791-3699.

TARGET AUDIENCE: This convocation is appropriate for directors of nursing, assistant directors of nursing, nurse managers and other clinical partners with intermediate to advanced levels of nursing expertise in post-acute care. Corporate consultants, clinical directors, nursing home administrators and other health care partners with direct resident care responsibilities are encouraged to participate as well.

VENUE & LODGING: Once you have registered, please secure your hotel reservation directly with Motor City Casino Hotel located at 2901 Grand River Ave, Detroit, MI 48201. A limited number of rooms have been designated for participants at the discounted group rate of $159++ per night if booked prior to Tuesday, October 1. Self and valet parking are complimentary at this venue. Room availability and/or the discounted group rate is NOT guaranteed. To reserve your room now:

Call 866-782-9622 and reference “NADONA” or “HCAM” ORVisit https://booking.motorcitycasino.com?package=125016

HCAM is proud to be the exclusive event manager for MI-NADONA/LTC. Additionally, HCAM is the provider of CNE in a joint-provider agreement with MI-NADONA/LTC.

welcome

sponsorsIC

QHealthcare

Contract • PRN • Travel • Home Care qcihealthcare.com

Where are you going?

Networking Highlights

• Annual Vendor Expo featuring 60 exhibitors with opportunities to win prizes and giveaways!

• Crystal Ball Evening Networking Party featuring the popular band Parallel Fifth, palm readings, tarot card readings, psychic future readings, and a green screen photo booth!

• Wellness Lounge featuring destress activity station with adult coloring books, diffused essential oils, guided meditations, soothing music and more!

Education Highlights

• Exceptional opening keynote Sandy Geroux sharing employee engagement tips to change your workplace to a WOWplace

• Thursday keynote Tyler Enslin will teach you how to master your memory

• Closing keynote from the Director of the Bureau of Community and Health Services with the State of Michigan

• 16 quality, nurse-focused educational sessions designed for LTC nurses with intermediate to advanced levels of nursing experience

Continuing Education

Final determination of contact hours will be published in the on-site program book.

NHA: This program has been submitted (but not yet approved) for Continuing Education for 13 total participant hours from NAB/NCERS. This program will include up to 1 pain CE.

RN: Nurse participants may also earn up to 13 nurse education contact hours. HCAM is an approved provider of continuing nursing education by the Wisconsin Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation.

TIME PROGRAM/EVENT

7:30 AM Registration Opens

9:00-9:15 AM Welcome & Opening Remarks

9:15-10:15 AM

Opening Keynote: Turn Your Workplace into a WOWplace: 5 Rules for Leading Your SNF to SuccessPresented by Sandy Geroux

10:30-11:30 AM

Advanced Heart Failure Treatment Options Presented by Angela Rose

What is Your Emotional Logo?Presented by Sandy Geroux

11:30-1:00 PM Awards & Recognition Luncheon

1:10-2:40 PM Person Directed Care Presented by Sandy Place

2:55-4:25 PM

Advance Care Planning: Starts TodayPresented by Margaret Chamberlain and Sara Damiano

4:25 PM Evening on Your Own

TIME PROGRAM/EVENT

8:00 AM Registration Opens

8:30-9:00 AM General Membership Meeting

9:00-10:00 AMThursday Keynote: Mastering Your MemoryPresented by Tyler Enslin

10:15-11:15 AM Success Strategies with PDPMPresented by Leah Klusch

11:30-12:30 PMEssential Oils and the Healthcare Industry (Pain CE)Presented by Terri Selden

MDS & Neurobehavioral Disorders (No CE Available) Presented by Cindy Fronning

12:30-1:30 PM Attendee & Exhibitor Luncheon

1:30-2:30 PM Infection PreventionPresented by Cindy Fronning

Nurses and AddictionPresented by Lisbeth Votruba

2:30-4:30 PM Annual Vendor Expo Show

4:30-5:30 PMBehavioral Health & Trauma Informed CarePresented by Dr. Phil Chauvin

CMS Release of Information on Adverse EventsPresented by Vickie Burlew

5:30-7:30 PM Attendee Break

7:30-10:30 PM Crystal Ball

TIME PROGRAM/EVENT

8:00 AM Registration Opens

8:30-9:00 AM Closing Remarks & Prize Drawings

9:00-10:00 AMClosing Keynote: LARA UpdatePresented by Larry Horvath

10:15-11:15AM

Weed, Sex & LeavePresented by DeAndre Harris, Brianna Richardson, and Kristin Sheets

11:30-12:30 PM ROP Phase 3Presented by Vickie Burlew

12:30 PM Conclusion of Conference

SCHEDULE AT A GLANCEWEDNESDAY, OCTOBER 23 THURSDAY, OCTOBER 24 FRIDAY, OCTOBER 25

PresidentBonnie Buellathebeullas@gmail.com

Vice PresidentCheryl Pattoncheryl@meadowbrookmcf.com

Immediate Past Chair & ProgramsShari Carsonslcarson@comcast.net

SecretaryAllison Lameyalamey@warwicklc.com

TreasurerDawn DeCampddecamp@laurelhealth.com

ScholarshipsDonna Beebegerald.beebe@yahoo.com

MembershipEllie Posterekposter@aol.com

NominatingJulie Pudvayjpudvay@ingham-mcf.org

Bylaws & MediaLinda Mondouxstratltc@gmail.com

Area 1 Etta Brownadministrator@fairlanescr.comMacomb, Oakland & Wayne counties

Area 2 Lynae Carsonlynaeanncarson61059@gmail.comBay, Gratiot, Isabella, Midland & Saginaw counties

Area 3 Mischelle Peelnursemischelle@yahoo.comIonia, Kent, Mecosta, Montcalm, Muskegon, Newago, Oceana & Ottawa counties

Area 4 Jim Prestonjimpreston@alamonh.netAllegan, Barry, Berrien, Branch, Calhoun, Cass, Kalamazoo, St. Joseph & Van Buren counties

Area 5 Renee Cunninghamrcunningham@mhc.netAlcona, Alpena, Arenac, Crawford, Gladwin, Iosco, Montmorency, Ogemaw, Oscoda, Otsego & Roscommon counties

Area 6 Angela Batesabates@houghtonmcf.comIron, Baraga, Gogebic, Houghton, Ontonagon, Keweenaw counties

Area 7 Brenda Palmer1bpalmer62@gmail.comClinton, Eaton, Ingham, Livingston & Shiawassee counties

Area 8 Kim Shaughnessykim.shaughnessy330@comcast.net Hillsdale, Jackson, Lenawee, Monroe & Washtenaw counties

Area 9 Jeanne Ricejrice@villahc.comDelta, Menominee, Dickinson, Marquette, Alger, Schoolcraft counties

Area 10 VacantLuce, Chippewa, Mackinac, Emmet, Cheboygan, Charlevoix, Presque Isle counties

Area 11 Patricia Leonardpleonard@mrhcares.orgSt. Clair, Sanilac, Huron, Lapeer, Tuscola counties

Area 12 Cheryl Pattoncheryl@meadowbrookmcf.comClare, Antrim, Mason, Manistee, Benzie, Leelanau, Grand Traverse, Kalkaska, Wexford, Missau, Lake,Osceola counties

Area 13 Vacant Genesee county

AREA COORDINATORS

2019 MI-NADONA/LTC BOARD OF DIRECTORS

OPENING KEYNOTEPresenter: Sandy Geroux, WOWplace International, LLCInternational speaker, trainer, and author Sandy Geroux delivers motivational keynotes and training programs on creating WOW experiences. Sandy helps leaders master leadership skills and strengthen relationships to engage their teams.

Turn Your Workplace Into a WOWplace: 5 Rules for Leading Your Skilled Nursing Facility to Success!The mindsets and concepts of great leadership have been taught forever. In fact, we all know what to do; the difficulty comes in finding ways to do it consistently, even in the face of disengagement and business/personal pressures. Additionally we all have “blind spots” when it comes to our own thoughts and behaviors that are hard for us to recognize and even harder for others to tell us. Sandy will share stories and insights that will help you identify what you may be inadvertently doing to inhibit employee engagement and contribution. She will share a successful formula for creating cultural consistency in the midst of human inconsistency and allowing everyone to respond respectfully and compassionately when human mishaps occur.

ADVANCED HEART FAILURE TREATMENT OPTIONS: LVADS AND MILRINONE INFUSIONPresenter: Angela Rose, Michigan MedicineTreatment options for advanced heart failure are constantly evolving and often include continuous infusion of milrinone and long-term mechanical circulatory support, or LVAD (left ventricular assist devices). As these therapies become more prevalent, health care providers are increasingly likely to encounter them in their daily practice. Long-term care facilities will be called upon to accommodate them, and may even cultivate a niche in an underserved care population. This session will offer a foundational overview of care concepts in continuous milrinone infusion and LVADs including indications for use, side effects and nursing considerations of milrinone infusion, description of LVADs currently in use in the U.S., common complications and their initial management, equipment issues, and care principals such as blood pressure measurement, driveline dressing care, and medication management. Although these therapies are sophisticated and technologically advanced, the elements of care are easily understood, standardized and implemented, often with the support of local advanced heart failure centers.

Wednesday Sessions

Wednesday SessionsWHAT IS YOUR EMOTIONAL LOGO?Presenter: Sandy Geroux, WOWplace International LLCWhether we realize it or not, we all have an “emotional logo.” It consists of one (or more) actions, gestures or words that leap to mind when people think about you. In other words, it’s how we’re “branded” in the minds of others. And that branding can either help us be incredibly successful as leaders – or stifle our effectiveness without us ever realizing why (or that) it is happening. The good news is that with self-awareness, focus and practice, we can make that logo anything we wish it to be. Sandy will explore how and why our logos are formed, what inadvertent messages they may be sending to our teams, and what we can do to ensure they are true “WOWs!” for everyone we wish to lead or influence.

PERSON DIRECTED CARE: RIGHTS, REGS AND REASONS Presenter: Sandy Place, Rolf ConsultingThe latest regulatory update requires the provision of Person Directed Care and outlines this through the Resident Rights tags and the Critical Element Pathways. For some facilities, there is confusion on what this means, how to grow a culture that supports person directed care, the costs involved and what operational pressures might have to be faced. This session guides your teams through defining and outlining what Person Directed Care is and how to meet the challenge of implementation.

ADVANCE CARE PLANNING: STARTS TODAYPresenters: Margaret Chamberlain, Rolf Goffman Martin Lang LLP and Sara Damiano, Beaumont HealthNinety percent of people say that talking with their loved ones about end-of-life care is important, yet twenty-seven percent have actually done so (The Conversation Project National Survey, 2013.) Learn the barriers and basics of advance care planning (ACP) and the difference between an advance directive and a MI-POST form from a practical and legal perspective, so you can improve patient care, enhance the provider experience, and stay in compliance.

THURSDAY KEYNOTEPresenter: Tyler Enslin, Tyler Enslin International From the age of 17, when Tyler started his first successful business, he realized that his favorite part of any day was helping people. in 2018, he launched Tyler Enslin International with this mission: providing lively, engaging, and practical keynotes to audiences around the country.

Mastering Your MemoryThe human brain possesses an incredible

amount of power to store and recall information. Unfortunately, most people are never taught how to fully access this ability. Join Tyler to learn unique and exciting methods to increase your memory skills to extraordinary levels. Most importantly, discover how to use these new skills in daily life. Instantly recalling people’s names, giving presentations without notes, and improved mental organization are just a few of the practical benefits from this intriguing program. Tyler delivers the training in energetic fashion with no notes or PowerPoint to encourage maximum audience participation and to impart as much value as possible to all who attend.

SUCCESS STRATEGIES WITH PDPM Presenter: Leah Klusch, The Alliance Training CenterWhat are the key issues with PDPM? This interactive session will look at the key management and operational issues that must be addressed for data and payment success. Join Leah as she reviews her strategies for payment and documentation success.

THE INTEGRATION OF ESSENTIAL OILS INTO THE HEALTHCARE INDUSTRYPresenter: Terri Seldon, The Oils Nurse LLC | doTERRA InternationalOpen your mind to natural alternatives to healthcare and the way these can be integrated to provide the safest, healthiest, and best quality way to care for our patients without harming the bodies homeostatic state. Terri will share the benefits of essential oil use as a major connection with the wellness pyramid, how oils can assist in addressing chronic illness as well as preventive medicine, and positive opportunities that essential oils can make in providing an integrative method for quality healthcare to our patients.

MDS AND NEUROBEHAVIORAL DISEASESPresenter: Cindy Fronning, NADONANO CE AVAILABLEThrough case scenarios and discussion, this session will provide an increased awareness of the MDS requirements regarding diagnoses as well as provide trainer content and tools for the DON

Thursday Sessions

and nurse leaders to use in their facilities. Resources and clinical tools provided will include neurobehavioral symptoms, diagnoses, assessments and care plans with interventions such as such PBA.

INFECTION PREVENTION: WHAT’S IN YOUR FUTURE?Presenter: Cindy Fronning, NADONAPhase 3 is almost here! Are you ready for the changes in the Infection and Preventions tags? Are your policies and procedures up-to-date and contain all the necessary components? Do you have all the policies and procedures that are required? Are you confident that your future will be citation free? This presentation will highlight the changes and potential areas that citations could occur. Attend and take home a P&P checklist and other resources to use to make the future of Infection Prevention in your facility as positive as possible!

NURSES AND ADDICTION: HOW ARE WE TAKING CARE OF OUR OWN?Presenter: Lisbeth Votruba, AvaSureThe disease of addiction does not discriminate, and nurses are not immune. DONs are therefore faced with the challenge of balancing their ethical duty to provide safe care with the duty to support the recovery of their employees from this treatable disease. In this session, Lisbeth will discuss the structure and process put in place to address this issue by the state of Michigan.

BEHAVIORAL HEALTH AND TRAUMA INFORMED CAREPresenter: Dr. Phil Chauvin, Deer OaksThis presentation describes trauma-informed care as it relates to this year’s newest phase of CMS regulation effective Nov. 28. Phil will identify types of traumatic events, describe physical and mental manifestations of trauma, and provide strategies for person-centered response plans when residents disclose trauma histories. He will review and discuss interpretations of the trauma-informed guidelines, related F tags, the Behavioral and Emotional Status Critical Element Pathway used by state survey, and assessment tools for staff. Walk away with four actions steps to prepare your community for person-centered trauma-informed care.

CMS RELEASE OF INFORMATION ON ADVERSE EVENTS Presenter: Vickie Burlew, Rolf Consulting | Lebenbom & RothmanLong term care has historically focused on identifying “unusual occurrences” after they occur and addressing them on a retrospective basis. As we move forward with Quality Assurance Process Improvement (QAPI) programs it is a key step to identify and address adverse events as they occur. Join Vickie Burlew in discussing how you can incorporate the CMS Adverse Drug Event Trigger Tool, AMDAs Quality Prescribing Guidelines, and the CDC Assessment Tool for LTC to identify potential adverse events, drive cycles of improvement and enhance resident outcomes.

Friday SessionsCLOSING KEYNOTEPresenter: Larry Horvath, LARA-State of MichiganLarry currently serves as the director of the BCHS within LARA. The bureau has regulatory oversight for state licensing of facilities, agencies and programs in Michigan. In addition, the bureau is the state agency in Michigan on behalf of CMS for providers interested in being certified to participate in Medicare and Medicaid.

State/National Regulatory Update & Practical Tips to Avoid Common Survey CitationsJoin Larry for an update on state licensure and federal certification requirements and processes and discussion of the Bureau’s priorities. Larry will discuss state and federal regulation interpretations that impact skilled nursing facilities, and detail common deficient practices with practical tips to avoid survey citations

WEED SEX & LEAVEPresenters: DeAndre Harris, Kaitlin Sheets & Brianna Richardson, Warner Norcross + Judd LLPLegal developments surrounding the workplace have left employers with more questions than answers these past few years. What does the new recreational marijuana law and Paid Medical Leave Act mean for employers in Michigan? What impact, if any, has the #MeToo movement had on harassment and discrimination in the workplace? In this session, we will discuss these issues and help employers remain compliant in today’s ever-changing workforce.

ROP PHASE 3Presenter: Vickie Burlew, Rolf Consulting | Lebenbom & RothmanCMS will implement Phase 3 of the Requirements of Participation on 11/28/19. Are you ready? In this session we will discuss the new requirements for Infection Control, implementation of QAPI, Compliance and Ethics, Physical Environment, and Training. We will provide you with websites and resources to implement.

Join Us for the Crystal BallThursday, October 24 | 7:30-10:30 PM

The SoundBoard at Motor City Casino Hotel

Live Performance

from Detroit Band

Parallel Fifth

See Your Future Through Tarot

Card Readings, Palm Readings

and Psychic Future Readings

Lights Camera Action - Grab

Your Friends for a Photo in the

Green Screen Photo Booth

expo

PROUDLY FEATURING:as of July 26, 2019 360care5 Star TelemedAdvaCare SystemsAll Med Medical SupplyBehavioral Care SolutionsCalmoseptine, Inc.CareerStaff UnlimitedCareLinc MedicalCompass Communications GroupDeer Oaks Behavioral HealthdoTERRA - The Oils Nurse, LLCElara CaringFitzsimmons Hospital ServicesHomeTeam Mobile DiagnosticsHomeTown PharmacyMcKesson Medical-SurgicalMcLaren Health Management Group

Mobile Care GroupMyriad Neuroscience - GeneSightNexcare Health Systems / The WellBridge GroupOmnicare / a CVS Health CompanyOn-Site Dysphagia Diagnostics PCA PharmacyPolaris Pharmacy ServicesPS of MIQCI HealthcareQuality Plus PharmacyRemedi SeniorCareResidential Home Health & HospiceSpan-AmericaWound K-Air Management

Wellness Lounge.Throughout the conference, enjoy the wellness lounge at your leisure. The room will feature aromatherapy diffusers, hemisync rain sounds, low lighting, soft seating, a stress relieving activity station including adult coloring books, guided meditations and massage therapists.

Take a moment to step into this safe space to unwind, relax your mind and prepare yourself to engage more fully in the conference sessions.

HCAM/MI-NADONA REGISTRATION POLICIES

REGISTRATIONRegistration forms should be mailed to HCAM at 7413 Westshire Dr., Lansing, MI 48917 or faxed to (517) 627-3016. The discounted early bird rate is available to current MI-NADONA/LTC members only, whose registration is received by HCAM by September 20, 2019.

EVENT CONFIRMATION After your registration form has been processed, an event confirmation will be emailed to you. Please be sure to include a current email address on this form. If you do not receive a confirmation within 14 business days, please contact Kisti Boatright via email at KistiBoatright@hcam.org.

CANCELLATION All refund requests must be made in writing to KistiBoatright@hcam.org. Individual registration fees, less a 25% processing fee, will be refunded for cancellations received in writing prior to September 20, 2019. Cancellations received after September 20 and no-show registrants, will not receive a refund nor a credit to a future program.

SUBSTITUTIONSIndividuals registered to attend this program, but unable to participate, may send an alternate in their place. Please contact Kisti at KistiBoatright@hcam.org with the first and last name, title, and facility/company of both the original registrant and the alternate to process this request.

QUESTIONSShould you have questions, please contact Kisti by phone at (517) 622-6194 or by email at KistiBoatright@hcam.org.

DIETARY REQUESTSDietary restrictions must be indicated on the registration form in order to receive a special meal at food functions. We take every precaution possible, however we cannot guarantee that items are free of trace amounts of allergens and other ingredients.

VIDEOS & PHOTOGRAPHY Registration, attendance at, or participation in the MI-NADONA/LTC Annual Convocation & Expo and other activities constitutes an agreement by the registrant to the use and distribution (both now and in the future) of the registrant or attendee’s image or voice in photographs, videotapes, electronic reproductions, and audiotapes of such events and activities by MI-NADONA/LTC, HCAM and other third parties.

CONFERENCE ATTIREBusiness casual attire is suitable for all meetings, sessions, and receptions. Please remember to bring a sweater or jacket for air-conditioned rooms.

CREDIT/CONTACT HOUR REPORTINGHCAM/MCAL will need 30 days to compile and process all scan data. Once the data is compiled, certificates will be available to access via our online system. Certificate questions should be directed to Kisti Boatright. Session attendance for administrators will be reported to NAB using their NAB Registry ID. Nursing hours will be reported to ANCC.

HCAM/MI-NADONA REGISTRATION POLICIES

CODE OF CONDUCT HCAM and MI-NADONA are committed to providing a safe and welcoming environment for all participants. We expect everyone associated with our conference to act responsibly, behave courteously, and respect the rights and dignity of others at all times while in attendance. HCAM reserves the right to remove or refuse service to anyone deemed to be in violation of this Code of Conduct.

The following actions are prohibited at our Convocation & Expo:• Harassment or intimidation by words, gestures, or body language• Physical contact with another person in an angry, aggressive, or threatening way• Verbally abusive behavior, including angry or vulgar language, swearing, name-calling, or shouting• Sexually explicit conversation or behavior

GENERAL CONFERENCE POLICIES• HCAM and MI-NADONA/LTC are not responsible for loss, damages or injury to persons or property occurring at or as a result of the conference or any related events.• Conference Attendee List Disclosure: HCAM and MI-NADONA do not sell attendee registration information to third-parties. We do share registration information (name, title, facility - no email addresses) with the current year’s conference sponsors/exhibitors and with whom we are partnered. If you prefer, you may opt-out during the registration process.• The views or opinions expressed by any attendee, speaker or sponsor are not necessarily the views or opinions of HCAM or MI-NADONA.

OPEN SEATING HCAM and MI-NADONA do not pre-register for individual sessions. We try very hard to ensure there is a seat for anyone interested in attending a session and we max out the number of seats in each room. However, there will be times when a session will run out of available seats.

For your safety, and because of fire regulations, meeting rooms that fill to capacity will be restricted. HCAM staff and convention center personnel must follow local fire regulations and will ask participants in overcrowded rooms to leave the room. Standing or sitting on the floor is not an option; only persons occupying a chair will be allowed to remain in the session.

REGISTRATION PACKAGE INCLUSIONSPackage A: Full Conference PackageThis package includes all education sessions, opportunity to earn up to 13 CE hours, all provided convention meals/refreshments, Awards Luncheon, Vendor Expo, and the Crystal Ball held Oct. 23-25. Package B: Wednesday ONLYThis package includes education sessions, opportunity to earn up to 5 CE hours, breakfast, Awards Luncheon, refreshments on Wed. Oct. 23 ONLY.Package C: Thursday ONLYThis package includes education sessions, opportunity to earn up to 5 CE hours, breakfast, luncheon, Vendor Expo, refreshments, and the Crystal Ball on Thursday, Oct. 24 ONLY.Package D: Friday ONLYThis package includes education sessions, opportunity to earn up to 3 CE hours, breakfast, and refreshments on Friday, Oct. 25 ONLY.Package E: Networking Pass for 2019 Exhibitors & Sponsors ONLY This package is limited to 2019 Exhibitors and Sponsors ONLY. This package includes lunch, Vendor Expo, and the Crystal Ball on Thursday, Oct. 24 ONLY.

Where will you be tomorrow?• October 23-25, 2019 •

MI-NADONA/LTC ANNUAL CONVOCATION

Payment Information

Payment Method:

Credit Card Number:

Security Code:

Cardholder Signature:To register now, submit this form by fax to (517) 627-3016 or by mail to HCAM, 7413 Westshire Dr, Lansing, MI 48917

Attendee Information

Attendee Name:

Attendee Title:

Attendee Email:Emergency Contact Name:

Facility Information

Facility/Company:

Address:

City: State: Zip:

Phone:

Special Dietary Needs:

Visa Mastercard American Express

Individual Membership Status

Current MI-NADONA Member Non-Member

Opt-OutHCAM|MCAL provides an attendee list of all registered attendees with name, title and facility only to partners and presenters. This list does NOT contain contact info such as email or phone. To opt-out of being included in the attendee list, please select opt-out on this registration form.

*In order to receive NAB CEs for this conference, attendees with an NHA license must sign up with NAB for a CE Registry number. That number must be shared with HCAM/MCAL at the time of registration or no CEs will be given. For more information go to https://www.nabweb.org/ceregistry.

Date:

Discover Check/Money Order Payable to “HCAM”

CE Information

NAB Registry ID*: Nursing License*:*In order to recieve RN CEs for this conference, attendees must provide their nursing license number to share with ANCC.

Vegetarian Vegan Kosher

Life-Threatening Allergy to: Moderate Allergy to: Mild Allergy to:

Registration Packages & Rates: Early Bird Registration Rates Expire Friday, September 20A: Full Package

Early Member: $450

Member: $525

Non-Member: $650

B: Wed., Oct. 23 ONLY

Early Member: $350

Member: $425

C: Thurs., Oct. 24 ONLY

Early Member: $350

Member: $425

D: Fri., Oct. 25 ONLY

Early Member: $350

Member: $425

E: Networking Pass for 2019 Exhibitors & Sponsors ONLY

2019 Exhibitors: $250

2019 Sponsors: $250

TOTAL AMOUNT DUE:

Non-Member: $500 Non-Member: $500 Non-Member: $500

Expiration Date: Billing Zip Code:

Emergency Contact Phone:

Form #112015

MEMBERSHIP APPLICATION A Membership Organization dedicated to Nurses in the Long Term Care Continuum

Make check or money order payable to: NADONA/LTC, 1329 E. Kemper Road * Suite 4100A * Cincinnati, OH 45246 FOR Credit Cards only - fax request to (513) 791-3699

Apply for membership on our website with Visa/Mastercard/American Express/Discover @ www.nadona.org Membership question? Call NADONA/LTC toll free 800-222-0539 or Email us at membership@nadona.org

□ New □ Renew Please print clearly (use one form per applicant or update renewal notice information) Tell Us About You Select all that apply: CDONA FACDONA CALN CLPN GDCN First Name Last Name

Home Address City State Zip

Home Phone Home Email

Tell Us About Your Career □ Skilled Nursing □ Assisted Living □ Retired

Corporation Facility/Community Name

Facility/Community Address City State Zip County

Facility Phone (please include extension) Work Email

Title License# and State Issued Type of license (RN, LPN, LVN)

Membership Dues PLEASE SUBMIT FEES FOR DUES AS LISTED BELOW

If you do not see your state, inquire about beginning a chapter in your state!

STATE 1 YR 2 YR STATE 1 YR 2 YR STATE 1 YR 2 YR STATE 1 YR 2 YR

Alabama $110 $195 Illinois $115 $210 Mississippi $110 $195 Ohio $130 $235 Arizona $115 $200 Indiana $115 $200 Missouri $120 $210 Oklahoma $115 $210 Arkansas $110 $190 Kansas $115 $200 Montana $110 $195 Pennsylvania $115 $205 California $110 $200 Kentucky $115 $210 Nevada $130 $235 South Carolina $115 $210 Colorado $110 $200 Louisiana $110 $200 New Hampshire $115 $200 Tennessee $115 $210 Connecticut $115 $210 Maine $110 $200 New Jersey $130 $235 Texas $125 $225 Florida $125 $230 Maryland $125 $230 New Mexico $115 $210 Virginia $115 $200 Georgia $115 $205 Massachusetts $125 $215 New York $120 $215 Washington $115 $210 Hawaii $120 $220 Michigan $120 $220 North Carolina $115 $210 West Virginia $110 $200 Idaho $110 $195 Minnesota $115 $210 North Dakota $125 $230 Wyoming $110 $195

For all States not listed, please pay $90.00 for one year; $160.00 for two years membership How Would You Like to Pay? □ Check Enclosed □ Visa □ MasterCard □ American Express □ Discover

Name as it appears on card: ___________________________________________________________________

Billing Address (if different from above) __________________________________________________________

Card#: ______________________________________________________ Expiration Date: ____/____

Signature: _______________________________

Contributions or gifts to the National Association of Directors of Nursing Administration in Long Term Care, Inc. are not tax deductible as charitable contributions.

However, they may be deductible as ordinary and necessary business expenses.