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Registration

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* 1. Organization

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* 2. Mailing Address

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* 3. City

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* 4. State

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* 5. Zip Code

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* 6. We strongly encourage pre-payment of the DON ELITE chat five-part series. However, we will send an invoice if payment is not received. In an effort to ease the invoicing process, we are requesting contact information for the person responsible for receiving invoices.

LeadingAge Wisconsin needs to know some basic information about the contact person for your organization for the DON ELITE chat series. The contact person will be the individual with your organization who will serve as the program facilitator for your employees who will be participating in the DON ELITE chats. This is the person who will serve as the liaison between LeadingAge Wisconsin, the professionals at Pathway Health, and your employees. Your contact person will be the individual who will receive all future e-mails and information regarding the DON ELITE chat series, including session access information and updates.

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* 7. Contact Person's First Name

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* 8. Contact Person's Last Name

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* 9. Contact Person's Telephone Number

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* 10. Contact Person's E-mail Address

In the event that your "main contact person" is ill or unexpectedly out-of-the-office, please list a back-up contact person who will serve as the liaison between LeadingAge Wisconsin, the professionals at Pathway Health, and your employees. Both of your contacts will receive all future information regarding the DON ELITE chat series, including conference call access information and updates.

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* 11. Additional Contact Person's First Name

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* 12. Additional Contact Person's Last Name

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* 13. Additional Contact Person's Telephone Number

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* 14. Additional Contact Person's E-mail Address

The facility fee to participate in the DON ELITE chat series is $180 (this includes all five DON ELITE chats).

Your DON ELITE Chat participation fee is a facility fee, not an individual participation fee. This means there is no limit to the number of participants from your facility as long as all participants use only one internet connection for your entire facility.

Each DON ELITE chat will begin promptly at 10:00 a.m. and will run for approximately 90 minutes.
At this point, please go to the file menu on your browser and click on "print" to print this registration form. You must print this form before you click on the "done" button below. Once you have printed this form, then you must click on the "done" button below.

Please mail your printed registration form, along with the payment for your total registration fee ($180 per facility), to LeadingAge Wisconsin, 204 South Hamilton Street, Madison WI 53703. Please make all checks payable to LeadingAge Wisconsin.

If you prefer to pay by credit card, please fax a copy of this registration form to 608-255-7064, or e-mail (info@leadingagewi.org), and then call the LeadingAge Wisconsin office at 608-255-7060 to provide your credit card information. Thank you.

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