Registration for P.I.E.C.E.S. Program for Regulated Health Care Professionals working in Long Term Care Homes

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

Note: Please enter valid information in every field.

History

First Name:  

Last Name:  

E-Mail Address:   

Professional Designation:

What is your position within your facility?:

LTC Home Name:

LTC Home Address 1:

LTC Home Address 2:

LTC Home City:

LTC Home Postal Code:

LTC Home Phone Number:

 () - - - Ext:

LTC Home Fax Number:

 () - - - Ext:

DOC/DON First Name:

DOC/DON Last Name:

DOC/DON E-Mail Address:   

LHIN Region


Has someone from your organization participated in the P.I.E.C.E.S. Enabler/Leadership Program?

     If yes, name of Enabler Program Participant(s):

     Date of Enabler Program:

Do you have responsibility for providing care to persons with Alzheimer’s disease or related dementia and with other mental health and behavioural problems?

Do you have an active role in the day-to-day assessment, planning, and delivery of direct care?

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.