P.I.E.C.E.S. Leadership and Performance Improvement Program

Answer all of the questions on the form and click the submit button to complete the registration.

Note: An incomplete form will affect acceptance of your application! Enter valid information in every field.

History

First Name:  

Last Name:  

E-Mail Address:   

Address 1:

Address 2:

City:

Postal Code:

Phone Number:

 () - - - Ext:
What is your position within your facility? Title:
  1. Professional Designation:
  1. If other, please specify:

LTC Home:

Address 1:

Address 2:

City:

Postal Code:

Phone Number:

 () - - - Ext:

Fax Number:

 () - - - Ext:

Administrator/Manager First Name:

Administrator/Manager Last Name:

Administrator/Manager E-Mail Address:   

Region:


  1. Has someone from your organization previously participated in the Enabler Program?
  1. If yes, name of Enabler Program Participant(s):
  1. How many staff are currently employed who have graduated from the 5-day P.I.E.C.E.S. sessions in 1998, 2001, 2003, 2004 or 2005?
  1. Please provide the name of the Psychogeriatric Resource Consultant (PRC):

  1. Please pick how often you are in contact with your PRC:

Note: An incomplete form will affect acceptance of your application! Double check to ensure there is valid information in every field before you click submit.

After clicking the submit button you should get a page indicating your name and acknowledging that your application has been received.