GW NATIONAL EMERGING LEADERSHIP SUMMIT

Registration Application


Apply before May 9, 2012: Registration fee is $595. Notification of Acceptance: All applications are reviewed by a steering committee, and candidates will be notified within 1 week of final deadlines. Cancellation Policy: Accepted applicants can receive a full refund if the applicant notifies the NELS committee of cancellation more than 30 days before the start of the Summit. Accepted applicants forfeit all funds if the applicant notifies the NELS committee of cancellation with less than 30 days before the start of the Summit. Attendance Policy: Accepted applicants must plan to attend all the sessions to earn full CEUs and continue the mission of NELS - Professionals Leading Passionate Innovation.

Personal Information


Prefix
* First Name
* Last Name
* Gender	Male Female
* Date of Birth (mm/dd/yyyy)
* Age as of 06/01/2012
* Email Address
* Phone Number

Work Information


Job Title
Company/Organization
Address
Apt/Suite Number
City
State
Zipcode
Work Phone
Website



* Reference: Please submit a recommendation letter from a professional reference.


* One Page Statement: Submit a brief (250 words or less) statement outlining your experience in and commitment to the field of long term care administration. The statement should include the your name.


* Resume: Please submit your most current resume.




* Payment and Lodging Information. The complete Summit package includes a $595 registration fee and lodging expenses. Please select Complete Summit Package Option 1-4:

Option 1: $1,600 Includes Registration Fee and Single Occupancy Room Option 2: $1,640 Includes Registration Fee for one and Double Occupancy Room (guest not attending summit). Option 3:$ 1,700 Includes Registration Fee for one and Double Occupancy Room (guest ticket for DC sight-seeing tour and welcome dinner). Option 4: $2,100 Includes Registration Fee for two and Double Occupancy Room. Please provide the name of additional summit attendee sharing double occupancy room. Additional Name:



Willging Scholarship Program Individuals eligible to apply for the Willging Scholarhip include: Individuals who work in a AHCA/NCAL facility Are under the age of 40 years Worked as an administrator for less than 5 years
Application:

Provide proof that facility is an AHCA/NCAL member.


In 250 words or less, discuss how you would improve the healthcare administration profession in aging services.


For more information on Willging Scholarship Program *» Read more*



For questions, please contact: Dr. Douglas Olson, Project Director and Visiting Professor, UW-Eau- Claire olsondou@uwec.edu (715) 836-5067 Roulla Nau, Coordinator, The George Washington University gwltc@gwu.edu (202) 994-3127