Session Title:(Required)

Member Fee:(Required)

Non-Member Fee:(Required)

Care Center Type:(Required)

Skilled Nursing Facility

Assisted Living Community

SNF & AL Care Centers

Season Ticket(Required)

Yes

Venue

Please include the venue name for all in-person trainings. This information will be used on all material for the program.

Venue Address

Street Address Address Line 2 City ZIP Code

Start Date of Program:(Required)

End Date of Program:(Required)

Start Time(Required)

If it is a multiple day program or a series, please verify the correct times in the notes box at the end of the form.

End Time(Required)

If it is a multiple day program or a series, please verify the correct times in the notes box at the end of the form.

Six Week Deadline Date:(Required)

Format:(Required)

Program Type:(Required)

Program Capacity (In-Person Trainings)

Training Synopsis & Program Highlights:(Required)

Target Audience / Program Category(Required)

First Presenters Name(Required)

First Last

First Presenters Title(Required)

First Presenter's Organization(Required)

First Presenters Email(Required)

First Presenters Phone Number(Required)

First Presenters Biography(Required)

Second Presenters Name

First Last

Second Presenter's Title

Second Presenters Organization

Second Presenters Phone Number

Second Presenters Email

Second Presenters Biography

Notes:

Please include any additional presenters (name/title/organization/email/phone). If it is an in-person training, please convey how you would like the room set up. Please include any time differences, if it is a multiple day program.

CHCA Representative Responsible for this Program:(Required)

CHCA Education Development Form

CHCA Education Development Form

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