2012 NADONA Registration Brochure DRAFT.indd

2012 Michigan Chapter
Annual Convocation & Expo
Men
to
Hum Financ r
an R e
M
Qua anage esource
lity A men
ssu t
ranc
e
•
•
Nov. 7-9, 2012 Shanty Creek Resort Bellaire, MI
2012
Convocation
SPONSORS
NICHOLS
2012 Michigan Chapter
Annual Convocation & Expo
This event is professionally managed by the Health Care Association of Michigan (HCAM).
MI-NADONA/LTC invites you to join nearly 200 of your professional colleagues
at this year’s convocation November 7-9 at Shanty Creek Resort in Bellaire, MI.
This year’s theme represents the multiple responsibilities DON’s must prioritize
and reprioritize on a daily basis to assure quality care. Don’t miss out on this
valuable opportunity to share ideas, best practices and collaborate to resolve
the issues of today.
Tuesday, Nov. 6
Thursday, Nov. 8
•
•
Early arrivals are invited to join the MI-NADONA/
LTC Board of Directors and relax during the Welcome
Networking Bonfire
Wednesday, Nov. 7
•
•
•
•
•
Keynote speaker, Jeanette Klemczak, will
discuss the implications of the MDCH Task Force
recommendations for Nursing Practice
Join us in celebrating & recognizing this year’s award
recipients at the Award & Recognition Luncheon
Experience a presentation on Mobile Technology
direct from the National NADONA Convocation!
Indulge in Spa Treatments including Massages,
Paraffin Treatments, Nail Polish Applications and a
Complimentary Drink Ticket for the Evening Signature
Drink
Get Cozy with Movie Night including popcorn, hot
cocoa and cash bar
•
•
•
Learn about Health Care Reform during a
presentation direct from the National NADONA
Convocation!
Experience the unparalleled networking of the
Annual Vendor Expo
It’s a Closing Night Celebration First! Experience
the thrill of Murder Mystery Dinner Theater. The
Murder Mystery Company is the nation’s most
popular mystery group. Come investigate the most
popular theater experience. Bring your detective
hat, magnifying glass and appetite...this will be one
KILLER night!
Following the Murder Mystery Dinner, there will
be Live Acoustic Entertainment by the bonfire with
s’mores and a cash bar
Friday, Nov. 9
•
Don’t forget to bid on spectacular items in the Silent
Auction!
CONTINUING
EDUCATION
Tues., Nov. 6: Evening Prior to Opening Day
8:00-9:30 pm
This year’s Convocation will
provide participants the
opportunity to earn up to
12 nurse contact hours.
HCAM is an approved provider of
continuing nursing education by the
Wisconsin Nurses Association,
an accredited approver by the American
Nurses Credentialing Center’s Commission
on Accreditation.
Participants may also earn up
to 12 licensed nursing
home administrator
contact hours.
Final determination of contact hour
approval will be outlined in the on-site
program booklet.
HCAM NEC
Nurse Education Committee
Lead Nurse Planner:
Shari Carson, RN, BSN, NHA
Activity Planners:
Vickie Burlew, ADN, NHA
Cathy Sunlin, MS, BS, ADN
HCAM Director of Education:
Denise Cook, BA, CMP
HCAM Education Assistant:
Mary Campbell, BA
Welcome Networking Bonfire for Early Arrivals
Wed., Nov. 7: Opening Day
8:00 am -5:00 pm
8:00-8:50 am
9:00-9:20 am
9:20-10:20 am
Attendee Registration
Continental Breakfast & Networking
Welcome & Opening Remarks by Chapter President Shari Carson
K1 - Opening Keynote: MDCH Task Force on Nursing Practice
Recommendations: Implications for Nursing in Long-Term Care
10:40-11:40 am
Concurrent Breakout Sessions:
W1 - Treatment of Neuropathy
W2 - The GROW Program
W3 - Person Centered Progress in MI: One Vision Moving Forward
11:45 am-1:15 pm Award & Recognition Luncheon
1:20-2:20 pm
Concurrent Breakout Sessions:
W4 - Simplify Your Time Everyday: Mobile Information Technology
W5 - The Age of Champions - a PBS film
W6 - Change is Inevitable: Except From a Vending Machine
2:40-3:40 pm
Concurrent Breakout Sessions:
W7 - When the Diagnosis is FTD: Frontotemporal Dementia
W8 - Advanced Care Planning and POLST Initiative
W9 - Advancing Excellence: What’s New in 2012/2013?
4:00-5:00 pm
W10 - Risk Management Trends
5:00 - 7:00 pm
Dinner on Your Own
7:00-9:00 pm
Indulge! Spa Services & Signature Drink
7:00-9:00 pm
Cozy Movie Night Outdoors with Hot Cocoa, Popcorn & Cash Bar
Thurs., Nov. 8: Vendor Appreciation Day
8:00 am -5:00 pm
8:00-8:45 am
8:50-9:50 am
10:10-11:10 am
11:30 am -12:30 pm
12:35-1:25 pm
1:30-2:30 pm
2:45-5:00 pm
5:45-7:45 pm
8:00-9:30 pm
Attendee Registration
Breakfast Buffet & General Assembly Meeting
T1 - Regulatory Issues Update
T2 - Navigating Health Care Reform: Creating a Road Map for Success!
T3 - Employment Law Updates: What Employers Need to Know
Attendee Lunch & Learn
T4 - QAPI
Vendor Expo Show
Closing Night Celebration: Murder Mystery Dinner & Cash Bar
Closing Night Celebration: Bonfire with Live Music, Hot Cocoa & Cash Bar
Fri., Nov. 9: Closing Day
8:00 am-12:30 pm Attendee Registration/Information
8:00-8:45 am
Continental Breakfast & Networking
8:50-9:50 am
F1 - Other Elements of Health Care Reform Policy
10:10-11:10 am
Concurrent Breakout Sessions:
F2 - Doctors & Nurses, What a Pain!
F3 - Medication Errors & Adverse Drug Reaction
F4 - 2012 Beers Criteria
11:30 am-12:30 pm F5 - Infection Control: Do I Need This Antibiotic?
12:30 pm
Convocation Concludes
THURSDAY, NOVEMBER 8 • 2:45-5:00 PM
In alphabetical order at time of print:
Advanced Specialty Rx
Advanced Tissue
All Med Medical Supply
American Medical Technologies
Calmoseptine, Inc.
CareLinc Long Term Care
Compass Communications Group, LLC
First Quality Products, Inc.
Great Lakes Caring Home Health & Hospice
HomeTown Pharmacy
HPSI Purchasing Services
In Touch Pharmaceuticals, Inc.
Invacare Continuing Care
Medical Staffing Network
Mobile Medical
MobilexUSA
Connect
Novartis Pharmaceuticals
Omnicare Pharmacies of Michigan
with
OnHealthcare
vendors
PharMerica
Win
QCI Healthcare
Residential Home Health & Hospice
prizes
Scrubs on Wheels
Scavenger
Trilogy Health Services
Hunt
WoundRounds
2012 MI-Chapter Annual Convocation & Expo
K1 - MDCH Task Force on Nursing Practice Recommendations: Implications for Nursing in LTC
By Jeanette Klemczak, MSN, BSN, RN, FAAN
Nursing Practice in Michigan and the Nation is undergoing dramatic change with the aging of both the population and the nursing
workforce. Health care service demands will only increase in the next two decades. Key initiatives such as the MI Nursing Education
Council and the Task Force on Nursing Practice are positioning nursing to serve as leaders for change in the profession as well as in
patient care. This session will inform and support nurses in long-term care for that leadership.
W1 - Treatment of Neuropathy
By Dr. Paul DeWesse, MD
Treatment for peripheral neuropathy has undergone dramatic developments in the past six years. Dr. Paul DeWeese will discuss a
new treatment that combines electronic signal therapy with nerve blocks. A recently completed published study of diabetic peripheral
neuropathy produced remarkable results in pain relief using the new treatment procedures. Dr. DeWeese will discuss his experiences in
using the new treatment in Michigan clinics and how patients have regained significant mobility as a result.
W2 - The GROW Program
By Mary Harroun, BS, MS, LNHA
The GROW Program was designed to change long-term care facilities to restorative facilities. By changing the facility culture to thinking
ambulation independence for every resident, the facility staff will become more involved with each resident and their care. The facility
will come under compliance of the F-tag 309, Quality of Care, and happier and more engaged residents will be soon realized as the result
of the GROW Program.
W3 - Person-Centered Progress in Michigan: One Vision Moving Forward
By Cean Eppelheimer, BS
One Vision: Moving Forward is a CMP-funded grant initiative that seeks to resolve questions and obstacles to the implementation of
person-centered practices in Michigan’s nursing homes. The One Vision stakeholder group is comprised of committed individuals
representing government agencies, providers, provider associations, resident and culture change advocates. This group is systematically
clarifying perceived regulatory barriers to person-centered NH practice through a group consensus process while also developing personcentered versions of the My InnerView tools. Please join us to learn about the One Vision process, the clarifications accomplished to
date and the new measurement tools that can help you measure your person-centered progress.
W4 - Simplify Your Time Everyday: Mobile Information Technology
By Angel McGarrity-Davis, RNC, CDONA, NHA
Is there a way to be more efficient, documentation regulatory compliant and make certain everyone who needs the information can have
access to it? Information Technology (IT) has been used in businesses and industries for years. IT allows information to be transferred
around the world in seconds. When are we in LTC going to help ourselves, our co-workers, our residents, our stakeholders, doctors
and even the environment by getting into the 21st century? Please follow me as we examine just how we can help improve our resident
quality outcomes, improve efficiency, and increase revenue by improving interdisciplinary team communication to do our jobs through
the use of mobile Information Technology.
W5 - MI-NADONA Debuts “The Age of Champions” - a PBS film
By Shari Carson, RN, BSN, NHA
“Age of Champions” is the award-winning documentary following five competitors who sprint, leap, and swim for gold at the National
Senior Olympics. You’ll meet a 100 year-old tennis champion, 86 year-old pole vaulter, and rough-and-tumble basketball grandmothers
as they discover the power of the human spirit and triumph over the limitations of age. This year, we’re launching a national “Host a
Screening” campaign to bring the film to communities across the country. We’ve created the Age of Champions Screening Kit to give
senior, health, and fitness organizations an easy-to-use tool to share the film with their members and promote the message of lifelong
health and wellness. Get involved with the campaign today!
W6 - Change is Inevitable - Except From a Vending Machine
By Katie Brown, RN, BSN & Barbara Smith, LBSW, MS, CHC
Understand reactions to change and explore ways to engage a wide range of staff within your organization to plan, implement and
embrace new initiatives.
W7 - When the Diagnosis is FTD: Frontotemporal Dementia
By Debra Mittelbach, BSBA, MAOM, LNHA, CDP, CALD
While Alzheimer’s Disease is highly publicized and still easily misunderstood, Frontotemporal Dementia is equally comparable yet more
distinguishable. Through research and clinical testing, FTD has been identified as a degenerative brain disorder that creates undeniable
personality changes, deteriorating language and motor skills along with cognitive dysfunctions. Learn more about the “other” dementia
known as FTD, its specific markers, and greater insight, through actual video testimonies, into the challenges families and affected
individuals face daily.
W8 - Advance Care Planning and POLST Initiative
By Carolyn Stramecki, MHSA, CPHQ & Julie Seitz, MSBA, RN
This program will provide an overview of advance care planning from the first steps as a healthy adult, to the last steps and end-of-life
care. The discussion topics include barriers to advance care planning, why it’s important, Michigan-specific regulations and the POLST
Pilot Project.
W9 - Advancing Excellence: What’s new in 2012/13?
By Audrey Stob, RN, CPHQ
The Advancing Excellence in America’s Nursing Homes Campaign has evolved into a key driver for nursing home quality
improvement. This presentation will showcase how the Michigan Local Area Network of Excellence (MI LANE) will drive
improvement in quality of life and care in Michigan Nursing Homes through a Learning and Action Network (LAN). The LAN
will convene providers, practitioners, and residents to build and share knowledge, spread best practices, and achieve rapid, wide-scale
improvements.
W10 - Risk Management Trends
By Angie Szumlinski, BS & Erica Holman, BA, MSW
Risk management is more than a term used in the insurance business. Risk management should be a term that your entire facility is
familiar with as they deal with loss control issues on a daily basis. This program was developed to educate facility managers on the
process of loss control from a “feet on the floor” view. Identifying risk exposures, data collection, trending and analysis will be discussed
along with current loss statistics and interventions to assist in initiating change with a focus on risk management.
T1 - Regulatory Issues Update
By Vickie Burlew, ADN, NHA
The Regulatory Environment for nursing homes is on the brink of major change from both federal and state governments. In this
session you learn about those changes and develop strategies to pro-actively deal with these. We discuss changes to the survey process and
enforcement cycles. We look at proposed changes to the DNR statutes. You have the opportunity to work with the new QAPI tools
published by CMS. And lastly, you become prepared to address the issues triggering IJs across the state. You will leave knowing what
others in the room have learned about what has to be reported to the state.
T2 - Navigating Health Care Reform: Creating a Road Map for Success!
By Lisa Thomson, BS
Just when you think as a leader your team has implemented all of the MDS changes, the health care reform initiatives require us to stay
on top of our game and identify new tools, resources and education. This interactive workshop will provide an overview of the health
care reform initiatives directly affecting the post acute industry, tools, resources and strategies for keeping ahead of these changes.
T3 - Employment Law Updates: What Employers Need to Know
By Grant Pecor, JD, BA & Nicole Paterson, JD, BS
Interested in learning about recent legal developments and trends in employment and labor law affecting employers? In this informative
session, recent developments in federal and state legislation, case law, and National Labor Relations Board decisions will be discussed and
analyzed for trends and practical tips. Don’t miss the presentation to stay current in this ever-changing area of law.
T4 - QAPI
By Sandy Fitzler, BSN
Section 6102 ( c ) of the Affordable Care Act (ACA) requires all nursing homes to develop and implement a Quality Assurance and
Performance Improvement (QAPI) program. CMS is developing the prototype program and will provide assistance to help facilities
meet the QAPI standards. A four-state seventeen-facility pilot is currently underway to test and refine the standards with completion by
2013 and with regulation to follow. Providers need to understand the program intent and learn what they can do now to get ready.
2012 MI-Chapter Annual Convocation & Expo
F1 - Other Elements of Health Care Reform Policy
By Sandy Fitzler, BSN
Health Care Reform has been passed into law and sets an over arching goal to improve health care quality and outcomes across
all settings of care. Reform will have a high impact on nursing facilities and will require us to be more accountable and forge
new partnerships and collaborations throughout the continuum of care. Successful engagement in reform efforts will require the
development and adoption of best practices like chronic disease management and improving transitions of care. Providers must be
prepared for the changes and invest in staff to ensure they have the skills and training needed to achieve desired outcomes. This session
will provide an overview of key provisions in the Patient Protection and Affordable Care Act that will impact how providers operate
their facilities.
F2 - Doctors and Nurses, What a Pain! Collaboration Among Professionals to Improve Pain Management
By Dr. Patricia Schmidt, DO, FACOI, FAAHPM & Wendy Bongero, RN, BSN
Doctors and Nurses, What a Pain! Collaboration among professionals to improve pain management is a lively team-taught session that
will engage participants in some of the most “painful” situations that can occur when caring for residents in pain. Foundational material
of pain physiology, mechanisms of pain, medications and treatment modalities will be reviewed. Tools to enhance communication and
advocacy to identify and treat pain will be provided. Audience participation will be encouraged!
F3 - Medication Errors and Adverse Drug Reaction
By Tom Katofiasc, BS
This presentation will provide an overview of medication adverse drug reactions and medication errors. Items discussed will include
common areas for medication errors to occur and strategies to reduce the risk of medication errors. Also discussed will be common signs
and symptoms of adverse drug reactions, common meds that are prone to causing side effects in the elderly and strategies to limit the
extent of ADRs in the long-term care setting
F4 - 2012 Beers Criteria
By Dr. Mark Jackson, MD
The 2012 Beers Criteria identifies potentially inappropriate medications in the elderly and acts as a guide for medication review / QA
in the ECF.
F5 - Infection Control: Do I Need This Antibiotic?
By Dr. Mark Jackson, MD
Antibiotics are often overprescribed in the ECF setting, with undue cost, side effects and antibiotic resistance. Learn to recognize and
avoid unnecessary antibiotics.
MI-Chapter NADONA/LTC Leadership
A special thank you to the
MI-Chapter NADONA/LTC board of
directors for their extensive work in
planning this year’s Annual
Convocation & Expo.
2012 Board of Directors
President: Shari Carson
[email protected]
Vice President: Bonnie Beulla
[email protected]
2012 Area Coordinators
Area I: Etta Brown & Daniel Vasquez
[email protected]/[email protected]
Macomb, Oakland & Wayne counties
Area II: Lynae Carson
[email protected]
Saginaw, Bay, Midland, Isabella, Gratiot counties
Area III: Judi Christensen
[email protected]
Grand Rapids
Area IV: Beth Beam
[email protected]
Kalamazoo
Area V: Vacant
Treasurer: Michele Scicluna
[email protected]
Corresponding/Recording Secretary:
Carol Timmer
[email protected]
Scholarship: Robert Willis & Donna Beebe
Alcona, Alpena, Arenac, Crawford, Gladwin, Iosco, Montmorency,
Ogemaw, Oscoda, Otsego & Roscommon counties
Area VI: Tammy Lehto
[email protected]
Baraga, Gogeboc, Houghton, Iron, Keweenaw & Ontonagon counties
Area VII: Brenda Palmer
[email protected]
Clinton, Eaton, Ingham, Livingston & Shiawassee counties
[email protected]/[email protected]
Area VIII: Heather Luke
Nominating: Julie Pudvay
[email protected]
Hillsdale, Jackson, Lenawee, Monroe & Washtenaw counties
[email protected]
By Laws: Linda Mondoux
[email protected]
Membership: Ellie Poster
[email protected]
Programs: Shari Carson
Area IX: Tammy Lehto
[email protected]
Alger, Delta, Dickinson, Marquette, Menominee & Schoolcraft counties
Area X: Patty McClees
pmcclees@baybluffs.org
Charlevoix, Cheboygan, Chippeaw, Emmet, Luce, Mackinac & Presque
Isle counties
Area XI: Bonnie Beulla
[email protected]
[email protected]
Huron, Lapeer, Sanilac, St. Clair & Tuscola counties
Media: Mary Keane
Area XII/U.P.: Cheryl Patton
[email protected]
Founder: Peggy Godfrey
[email protected]
[email protected]
Antrim, Benzie, Clare, Grand Traverse, Kalkaska, Lake, Leelanau,
Manistee, Mason, Missaukee, Osceola & Wexford counties
Area XIII: Vacant
Genesee
Other Conference Information
LODGING ACCOMMODATIONS - SECURE BY OCTOBER 8
Please secure your hotel reservation directly with Shanty Creek Resort located at 5780 Shanty Creek Road, Bellaire, MI 49615. A block
of rooms has been reserved for participants at the discounted group rate of $91 per night plus applicable taxes if secured prior to
October 8. Shanty Creek Resort can be reached directly at (800) 678-4111. Parking is complimentary. For your convenience,
Shanty Creek Resort offers complimentary shuttle service to/from downtown Bellaire.
To secure your lodging accommodations now, please submit the Guest Room Reservation Form (see page 11). The Guest Room
Reservation Form is also posted to the association website at www.HCAM.org. You may also secure your lodging accommodations online
at http://reserve.shantycreek.com/?g=134144. Telephone reservations cannot be accepted.
CONFERENCE ATTIRE
Casual business attire is appropriate for the whole of this conference. Please remember that conference room temperatures are difficult to
regulate; please dress in layers for your comfort. Warm clothing is recommended for participation in the evening outdoor bonfires.
PRINTING SESSION MATERIALS
Since 2010, in an effort to be environmentally responsible, HCAM is trying to reduce the amount of paper used at educational programs.
Electronic program materials and handouts will be accessible online at the association website at www.HCAM.org, before, during and
following the conclusion of this program for registered participants to access and print. It is at the sole discretion of each presenter to
provide program materials and handouts. Instructions on how to access and print program materials will be e-mailed via “Know Before
You Go” to all registered participants (if e-mail address is provided on registration form) in the weeks leading up to the conference.
CERTIFICATION EXAMINATION
Since 1989, NADONA/LTC has certified directors of nursing and assist and directors of nursing for long-term care facilities. More than
1,800 professionals have been certified through this program. For more information about the Certified Director of Nursing in
Long-Term Care examination or to register to become a NADONA/LTC member, please visit www.NADONA.org.
2012 HCAM REGISTRATION POLICIES: PLEASE REVIEW PRIOR TO SUBMITTING YOUR REGISTRATION FORM
Registration
Please utilize the form on the back cover to register for the 2012 MI-Chapter
NADONA/LTC & Expo. Please mail or fax completed registration forms.
Early Registration Deadline
The discounted early registration rate is available to current NADONA members or
associate partners only, whose registration is received by HCAM by October 8.
Event Confirmation
After your registration form has been processed, an event confirmation will be
faxed to your attention. Please be sure to include a current fax number with area
code on the form. If you do not receive a confirmation within 14 business days of
submitting your registration form to our office, please contact HCAM via e-mail at
[email protected].
Payment & Applicable Rate
All registration fees are due at the time of registration. We accept Visa,
MasterCard, American Express or Discover. We will also accept a check or money
order payable to HCAM. Incorrect rates will be adjusted to reflect the correct
applicable rate and automatically charged accordingly.
Cancellation & Refund Policy
All refund requests must be made in writing by e-mail to the attention of Denise
Cook at [email protected]. Telephone cancellations will NOT be accepted.
Individual registration fees, less a 25% processing fee, will be refunded for
cancellations received in writing prior to Oct. 8. Cancellations received after
Oct. 8 and no-show registrants, will not receive a refund nor a credit to
a future program.
Substitutions
Individuals registered to attend this conference, but unable to attend, may send an
alternate in their place. Please contact HCAM via e-mail at eventconfirmation@
hcam.org with the first and last name, title, facility/company and e-mail addresses
of both you and your substitute to process this request.
Dietary Restrictions and/or Special Accommodations
Individuals with special dietary restrictions, or those who require special
accommodations to fully participate in this conference, should contact HCAM in
writing by e-mail to [email protected] no later than Oct. 8, detailing their
request or restriction. It is the responsibility of each participant to notify banquet
staff of their dietary request at each meal on-site.
Overnight Accommodations
To secure your hotel reservation, please use the Guest Room Reservation form
provided on page 11 or see above for more information.
Consent to Use of Photographic Images
Registration and attendance at, or participating in, HCAM or NADONA events and/
or activities constitutes an agreement by the registrant to HCAM and NADONA’s
use and distribution (both now and in the future) of the registrant or attendee’s
image or voice in photographs, videotapes, electronic reproductions and
audiotapes of such events and activities.
Questions
Should you have questions, please contact Denise Cook by phone at
(517) 622-6193 or by e-mail at [email protected] prior to the conference.
SUBMIT THIS
FORM DIRECTLY
TO SHANTY
CREEK RESORT.
Health Care Association of Michigan
November 6-9, 2012
134144
2012
October 6,8,2012
Reservations Must be Received By: OCTOBER
Reservation requests received after this date will still be accepted provided rooms are available.
PLEASE RETURN THIS FORM BY MAIL OR FAX TO:
Reservations Department • Shanty Creek Resorts
5780 Shanty Creek Road • Bellaire, MI 49615
Fax: 231.533.7004
Check-in begins at 6pm, Check-Out is 12pm
Name:__________________________________________________________________________________________
Address:________________________________________________
Home Phone: _________________________
City:_________________________ State:____
Zip:____________
Business Phone:________________________
Confirmation Email: ________________________________________
Fax: _________________________________
You are welcome to arrive early or extend your stay following this scheduled event. At times specified accommodations are not available prior
to or following your event. If the room type requested is not available, we reserve the right to assign the next available room type and rate.
Arrival Date: ________________
Departure Date:________________
# Adults:_______
# Children:______
ROOM TYPE:
1 Adult
2 Adults
3 Adults
4 Adults
______Guest Room (2 Beds)
$91
$91
$106
$121
______Parlor Studio (King Bed)
$110
$110
The above rates are Per Room, Per Day, plus 6% state tax, 9% resort fee and 5% TCCVB fee.
If your organization is state tax exempt you must furnish a copy of the state tax exemption certificate
when making your reservation.
THIS FORM MUST BE MAILED OR FAXED IN TO RECEIVE THE GROUP DISCOUNTED RATES.
st
Deposit Policy: You must guarantee your room reservation with a major credit card or a check for deposit of 1 nights lodging. Credit
card WILL BE charged for the above deposit. Use of Debit cards at the resort for lodging or deposits may cause your financial
institution to put a hold on your account for the total amount of the stay plus a $50.00 per night incidental charge. The resort
is not responsible for returned check fees resulting from this practice by your financial institution. Refund of your deposit will
be made if cancellation occurs at least 5 days prior to arrival, less a $10 handling fee.
Card Number: _______________________________________________
Expiration Date:_____________________
(If Mailing a Check, Please Note on the Line Above.) Reservation will be held for 10 days pending receipt of the check. If credit card
deposit is made and organization pays in full by check refunds of credit card are subject to a $10.00 handling fee.
Signature (Required): ____________________________________Printed Name ______________________________
Do you have any special lodging requests?
Barrier Free: ________________
Other (Please Indicate): _________________________________________
We do our best to honor special requests, however we cannot guarantee them.
For Questions or More Information, Please Call: 1-800-678-4111
2012 Michigan Chapter
To register, complete this form & submit with
payment by fax to (517) 627-3016 or mail to:
HCAM•7413 Westshire Dr., Lansing, MI 48917
Registration is also available online at
www.HCAM.org.
NADONA/LTC
Annual Convocation & Expo
Nov. 7-9, 2012 • Shanty Creek Resort • Bellaire, MI
Option
A
B
C
D
E
F
G
H
Description
To register, circle both the applicable package letter (left) and the applicable
corresponding rate (right). Fill in the total amount due (bottom right).
Full Convocation: Includes all convocation education, activities and meals November 7 - 9.
NADONA
Member Rate
Before Oct. 8
NADONA
Member Rate
After Oct. 8
Prospective
Member Rate
$349
$399
$525
$270
$350
$270
$350
$140
$185
$40
$60
$100
$140
$100
$140
Opening Day: Includes breakfast, education and Award & Recognition Luncheon on Wednesday, November 7 only.
This does not include evening networking functions.
Vendor Appreciation Day: Includes breakfast, education, luncheon and expo on Thursday, November 8 only.
This does not include evening networking functions.
Closing Day: Includes breakfast and education on Friday, November 9 only.
This does not include evening networking functions.
Award Luncheon: Includes the Award & Recognition Luncheon on Wednesday, November 7 only.
Opening Night Celebration: Includes Indulge: Spa Services, 1 drink ticket for the Signature Drink, and Cozy
Movie Night on Wednesday, November 7 only.
Closing Night Celebration: Includes Murder Mystery Dinner Theater and Acoustic Entertainment around the
Bonfire on Thursday, November 8 only.
Guest/Vendor Meals: Includes breakfasts, luncheons and breaks November 7 - 9 only.
$199
This does not include education or evening networking functions.
Total Amount Due $
Please Print Clearly/One Registration Form Per Person
Name:____________________________________________________________________________ Title:_________________________________________________________________________
Facility/Company:_______________________________________________________________________________________________________________________________________________
Address:_________________________________________________________________________________________________________________________________________________________
City:___________________________________________________________________________________________ State:____________________________ Zip: ________________________
Phone:__________________________________________________ Fax: _________________________________________ (Your registration confirmation will be sent by fax, if provided)
E-mail (required):_______________________________________________________________________________ (Important conference info. will be sent to you by e-mail, if provided)
Are you a NADONA/LTC member? (check one) ___YES ___NO • If yes, what is your NADONA/LTC Membership Expiration Date: ___________________
Payment Information
Check One: ____Check/Money Order made payable to “HCAM”
____Visa
____MasterCard
____American Express
____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:____________________________________________________
By submitting this registration form to HCAM, you acknowledge that you have reviewed and agree to all
HCAM policies stated on page 10 of this registration brochure, including the Cancellation & Refund Policy.