CHAMP - Curricula for Homecare Advances in Management and Practice

Please submit this form to register for the California CHAMP class starting in October 2008.

Deadline Date

Registrations, with the fee, must be received by September 30, 2008. This CHAMP course is only being offered for 50 agencies, so get your registration in early to ensure your participation!

All fields are REQUIRED.

Agency Information

Agency Name
Address
City
State
Zip

Agency Description (check all that apply):

	For Profit Free Standing Agency
	For Profit Hospital-based Agency
	Visiting Nurse Association Agency
	Other Non Profit Agency
	CAHSAH Member

Your Contact Information

Your Name
Title
Telephone
email

Tuition

Base fee includes tuition costs for up to three participants per agency. Additional participants are charged separately.

You may register either CAHSAH Members OR Non-Members, but not both.

	Base Fee (1-3 participants)	Each Additional Participant
CAHSAH Members	$1,000	$250
Non-Members	$1,300	$350

	How Many?	Cost
CAHSAH Members		$
Non-Members		$

Registration and Payment

To Pay by Check:

Use your browser’s print function to print this page and mail along with your check to:

Amy L. McGuire
Program Liaison, The CHAMP Program
Center for Home Care Policy & Research
Visiting Nurse Service of New York
107 East 70th Street, 5th Floor
New York, NY 10021

Click the Submit Registration button to complete your registration.

To Pay by Credit Card:

Simply click the Submit Registration button and follow the online payment instructions.