Please fill out and return this form with your check payable to:
NYCLTCEN, 2975 Independence Ave., Bronx, NY 10463 or fax this form to (718) 795-2572
CONFERENCE FEE:
$30.00 per person if received by mail before June 1, 2000.
$35.00 per person if received after June 1, 2000, including registration at the door.
$75.00 fee for three persons from the same facility; $80 late registration fee.
$15.00 fee for students, seniors, and ombudspersons; $20 late registration fee
This form may be duplicated to register additional people.
Please circle your two workshop choices.
A./E. Informed Consent
B./F. Advance Directives and Individuals with Dementia
C./G. Symptom Assessment and Therapy
D./H. Clinical and Ethical Issues in Hydration & Nutrition
Name:______________________________
Position:______________________________
Facility:______________________________
Address:______________________________
City:_________________State:_____Zip:________
Telephone Number:______________________________
Fax Number:______________________________
E-mail:______________________________
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