2 Dementia Simulation Training Scheduling Request

SCHEDULING REQUEST

Please fill in the form below. We’ll contact you as soon as possible.

First Name*
Last Name*
Company*
Area*
Address*
Street Address Address Line 2 City State ZIP Code
Email*
Phone*
I am interested in providing this training for the following number of people (max):*
I am interested in offering this training to attendees outside of our organization*
If possible, I would like to schedule this training seminar in the month of:*
I have a suitable environment to accommodate this training:*
1) Large “Welcome Room” for intro training, suiting up and wind down 2) “Task Room” for the actual Simulation Training 3) “Debrief Room” for post-training discussion 4) Two Staff members to assist ECGM Team
Fee schedule for this dementia simulation training:*
Comments
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You will be contacted as soon as possible.

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