Complex Care Workshop Registration Form

Complex Care Workshop: Addressing Social Needs in Dementia Care

Please complete the form below to register for the workshop, an initiative of the California Department of Health Care Services. Hosted by the Dementia Care Aware Medical-Legal Partnership Network. Participants of the workshop are eligible to receive 3 CME/MOC and CE credits or up to 3 hours of general MCLE credit. (MCLE Provider Number 9545)
Name*

First NameLast Name
Email Address*
example@example.com
Profession/Role*
If you selected "Other" for the previous question, please state your role/profession.*
Organization Name*
Organization Zip Code*
The DCA MLP Network can assist with covering the cost of hotel rooms for the first 15 registrants who require overnight accommodations. Once you have registered, the DCA-MLP Network will be in contact within 7 business days to confirm your accommodation.
Will you be requiring arrangements for a hotel room? (Note: Hotel room costs can be covered for first 15 people who register only! We will notify if you are eligible for hotel room coverage within 7 business days of registration. If you do not receive confirmation that we are covering your hotel, please proceed to book and pay for your own hotel arrangement)*

YesNo
If you selected "yes" to the previous question, which nights will you be requiring a hotel room?

Thursday nightFriday night
Please indicate if you have any of the following dietary restrictions:*

VegetarianVeganHalal / KosherNut-freeGluten-allergyNoneOther
Are there any accommodations you require to participate in this event?*

Please rank your interest in the following training topics (Breakout Session #1). First come, first served - space is limited. We will do our best to accommodate all participants' top preferences.*

	1	2	3	4
Advance Care Planning
Medi-Cal/IHSS/Long-Term Care
Consumer Debt
Elder Abuse

Please rank your interest in the following training topics (Breakout Session #2). First come, first served - space is limited. We will do our best to accommodate all participants' top preferences.*

	1	2	3	4
Avoiding Conservatorship
Paid Family Leave
Housing
Disability Forms

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Complex Care Workshop: Addressing Social Needs in Dementia Care

The DCA MLP Network can assist with covering the cost of hotel rooms for the first 15 registrants who require overnight accommodations. Once you have registered, the DCA-MLP Network will be in contact within 7 business days to confirm your accommodation.