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Please Fax to 417.865-5725
___________ ( Date of EDNA you wish to attend) End of Life Education for the Nurse Assistant TRAIN THE TRAINER Registration Form Name____________________________________________________Discipline (RN, CNA, LPN, Etc) _____________________ (Required for CEU Hours) Place of Employment____________________________________________________Department__________________________________ WORK Address______________________________________________City____________________________State_______ZIP________ Telephone (Work)________________________(Work Fax)________________________Home/Cell_________________________ HOME Address______________________________________________City____________________________State_______ZIP________ E-mail___________________________________ It is STRONGLY SUGGESTED that at least one discipline other than a Nurse Assistant attend from each facility to build a training network First Attendee from your facility $75.00_______________ Additional Attendees $50.00 ea___________________ Nurse Assistants (No Charge when TWO PAID persons attend) #’s__________________ (please complete a registration form for EACH attendee) Total Fees: ____________________________ Total # Attending: ______________________ Suggested Audience: This train-the-trainer course is designed for any person who will provide education to Nurse Assistants caring for patient/residents at the end of life See Brochure for CEU information: Hours provided for Licensed Nursing Home Administrators (PC hours) & Nursing. Social Work will be provided materials to submit. Please Fax Registration to: 417.865-5725 FAX And follow up via Mail with your check to: (sorry, we cannot bill you) REGISTRATION DEADLINE: Community Alliance for Compassionate Care SPACE IS LIMITED ~~ At the End of Life PLEASE RESERVE EARLY! KIM MORELOcK 1944 E. Sunshine, Suite C Springfield, MO 65804 417.865-4501 (Phone) 417.865-5725 (fax)
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