Register to learn more about upcoming events, get involved in one or more subcommittees, or volunteer to mentor others in the nursing home industry.

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Become a registered member of the coalition

Register for information about upcoming events or to get more intimately involved with the coalition. This registration form was designed to help coalition leaders manage participation efficiently and get participants involved in areas where they have demonstrated interest. Please take a few minutes to complete this questionnaire. Make sure to hit the "Submit" button at the bottom of the page when you are done.

First Name
Last Name
Job Title
Organization
Address
City
State	Zip
County
Email
Phone

Discipline:

Activities
Direct Care Professional
Nurse
Nursing Home Administrator
OT/PT/SLP
Physician
Social Worker
Other:

	Add me to the Ohio Person-Centered Care Mailing List so I can keep up-to-date on coalition educational offerings.
	Add me to the Ohio Person-Centered Care E-mail Listserv so I can keep up-to-date on coalition initiatives and confer with others in the industry about person-centered care practices.
	Conference Volunteer Although I am not interested in being an active member of the coalition's education committee, I would be willing to help with set-up and registration for conferences and other educational offerings.
	Nursing Home Open-Door Mentor Program My nursing home has been successful in implementing one or more person-centered care practices and we are willing and interested in opening our doors to other nursing home professionals in Ohio so they can see how we did it. The coalition is free to distribute my name as a mentor contact in the areas specified below, and I am willing to answer questions from other professionals about them. Furthermore, my nursing home doors are open to anyone who would like to see policies in practice. (Important note: Please be sure to gain approval from the proper members of your organization's administration before selecting this option)

We would like to spotlight the following care practice(s):
	Activities Program
	Bathing experience
	Care planning
	Dealing with death & dying
	Dementia
	Dining services
	Intergenerational programs
	Medication pass and/or schedule
	Mentoring program
	Neighborhood/community design
	Resident council
	Sleeping/waking schedules
	Staff recruitment, orientation, and/or retention practices
	Other:

I would be willing to be a guest speaker at future coalition conferences (or other educational offering).

I have connections that I would be willing to leverage on behalf of the coalition.

	Legislative
	Media
	Regulatory
	Other:
Please Explain

Steering Committee Member
I am interested in participating with the decision-making body of the coalition by actively participating in one of the sub-committees below, attending steering committee meetings, and dialing into both sub-committee and the general steering committee teleconferences. Steering Committee meetings are held monthly usually in the form of an hour long teleconference, with periodic face to face meetings last several hours. Sub-committee meetings are generally teleconferences lasting about an hour.

If interested in participating in the steering committee, please indicate which sub-committee(s) you would like to join.

	Assessment Committee - Assesses the prevalance of person-centered care practices in Ohio nursing homes.
	Education Committee - Plans and implements all educational offerings provided by the coalition.
	Public Relations Committee -Garners media and public attention for the coalition's efforts.
	Regulatory Committee - Bridges gaps between person-centered care practices and regulatory requirements.
	Resource Committee - Identifies and collects educational materials related to person-centered care and makes them available to the Ohio nursing home community.
	Website Committee - Designs and administrates the coalition website - www.centeredcare.org.
	I am interested in and willing to be a committee chair person.
	Contact me about this option. I would like to learn more.