4/25/2013 Future Leaders Brochure .pdf - Health Care Association ...

2013-2014 HCAM | MCAL
Future Leaders Program
Program Times:
Program Location:
Program Inclusions:
Please Note:
Questions:
12:30-4:30 PM EST (all modules)
HCAM/MCAL Offices located at 7413 Westshire Dr., Lansing, MI 48917 (all modules)
Registraon includes all required program/module materials such as handouts, books and movies.
Parcipants will need to have an email address that is checked on a regular basis and internet access for
ongoing email and forum based discussions in between modules. Parcipants may also be required to
complete reading/reviewing assignments in between modules.
Should you have quesons, please contact Lea Osborne at (517) 622-6189 or LeaOsborne@hcam.org
PLEASE CHECK ONE PROGRAM. ATTENDANCE OF MODULES I-IV FOR EACH PROGRAM IS REQUIRED.
_____ Future Leaders Program for Nurses
Module I: Jan. 10, 2013
Module II: Mar. 15, 2013
Module III: May 16, 2013
Module IV: Aug. 1, 2013
_____ Future Leaders Program for All
Module I: Aug. 8, 2013
Module II: Oct. 3, 2013
Module III: Nov. 21, 2013
Module IV: Jan. 23, 2014
_____ Future Leaders Program for All
Module I: May 10, 2013
Module II: July 11, 2013
Module III: Aug. 29, 2013
Module IV: Oct. 29, 2013
_____ Future Leaders Program for Nurses
Module I: Nov. 14, 2013
Module II: Jan. 16, 2014
Module III: Mar. 13, 2014
Module IV: May 8, 2014
PLEASE CHECK YOUR APPLICABLE REGISTRATION RATE.
_______ $350 HCAM/MCAL Member
_______ $575 Non-Member
PLEASE PRINT CLEARLY / ONE REGISTRATION FORM PER PERSON
Name:________________________________________________________ Title:______________________________________________________________
Facility/Company:__________________________________________________________________________________________________________________
Address:_______________________________________________________ City:_____________________________ State:Zip:___________
Work Phone:____________________________________ Fax: ___________________________________ Cell: ____________________________________
Email:_______________________________________________________________________ Confirmation & program info will be sent by email, if provided.
PAYMENT INFORMATION
Check One: ____Check/Money Order made payable to “MCAL” ____Visa ____MasterCard ____Discover
Credit Card Number:______________________________________________________________________
Expiration Date (month/year): _____________ Three-digit Security Code on Back of Card: ___________ Billing Zip Code for Credit Card: ___________
Cardholder Name (print):____________________________________________________________________________________________________________
Cardholder Signature:_______________________________________________________________________ Today’s Date:___________________________
Please remit completed registration form and payment to:
MCAL • 7413 Westshire Dr. • Lansing, MI 48917 or fax to (517) 627-3016