CANADIAN LTC NURSING LEADERSHIP FOUNDATIONS COURSE

Course Registration Form

LTC Clinical Shift Supervisor Training (Wednesday, November 27th from 8:30am to 4:30pm at Lincourt Manor, St. Stephen, NB )
Student Name*

First NameLast Name
Provincial Nursing Registration Number*
Work Phone Number
Mobile Phone Number*
Work E-mail
example@example.com
Personal E-mail*
example@example.com
Mailing Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear about us?*
Workshop Selection
Please Confirm The Following Workshop Date:

Wednesday, November 27th from 8:30am to 4:30pm at Lincourt Manor, St. Stephen, NB
Method of Payment

Tuition is $595 CAD + HST for a total of $684.25
Which payment method will you be using?*

Cheque (sent my mail)Credit card online
Cheque Payments: Cheque made payable to Beacon Clinical Group Inc. (please mail cheque to Beacon Clinical Group Inc, 105 Connell Street Unit 5, Woodstock NB E7M 1K7)

Credit Payment: We accept VISA/MASTERCARD via the online payment portal SQUARE (with a secure check out to protect your credit card information). Please indicate the email address where you would like to receive the digital invoice with online payment option
If you are paying via credit card, where would you like the invoice to be sent to?
example@example.com
Please click HERE if you are making a credit card payment.
Agreement of Participation
We ask that you honor our agreements of participation for this online course:
- Confidentiality: Students are encouraged to share personal reflections and experiences to further their own learning and foster group participation. Such information will be considered confidential and will not be shared outside of this learning experience by students and/or instructors.
- Attendance: Mandatory for both dates of the workshop in order to be awarded the certificate of “Long Term Care Shift Supervisor Course”.
- Be Stationary: Please be prepared to participate from a stationary spot. Participation from a moving vehicle, while on a walk, etc. is not ideal for this type of learning experience. 
- Full Engagement: Please have both your video and audio on through your computer, laptop, or mobile device and we encourage you to use headphones (not computer speakers) to enable the best experience for yourself and others.
- Full Presence: Please eliminate notifications, distractions, or anything that will take your attention from the experience. We do make an exception for lunch/snacks/drinks! Feel free to enjoy some nourishment as we chat together.  
- Course Grading: Participants are required to attend class and complete the homework assignments in order to be given credit for the course. The course is a pass/fail grading format. Upon successful completion of the course, students are awarded a certificate of completion. This course can be credited towards greater certifications within Beacon Clinical Group, including the Leadership in Person Centered Care credential.
I agree to honour the above agreement of participation:
Signature*

Powered by Jotform SignClear
Date*

MonthDayYear
Date
If you have any questions, please do not hesitate to reach out.

Cheyanne Culbert
Email: cheyanne@beaconclinicalgroup.com
Phone: (506) 425-7495
Should be Empty:

Course Registration Form

Workshop Selection

Method of Payment

Agreement of Participation