Emergency Department (ED) Call Coverage: What Hospital ...



Crucial Conversations® Training, Influencer Training® and

Crucial Confrontations® Training

Registration Form

Name: _________________________________________________________________

Title: __________________________________________________________________

Hospital/Institution: ______________________________________________________

Address: _________________________________ C/S/Z: _______________________

E-mail: ______________________ Phone: ________________ Fax: ______________

____ Payment Enclosed Amount: $ ____

Signature: _______________________________

The cost to attend is $99 per program. The registration fee includes all materials and lunches and covers only a small portion of the workshop. The majority of the cost is covered by the Greater Kansas City Healthcare & Healthcare Information Technology Careers Grant, which is funded by the American Recovery and Reinvestment Act through the U.S. Department of Labor-Employment and Training Administration. Program administrator is the Full Employment Council.

This grant requires participants to provide a copy of their driver’s license and Social Security card when they attend the workshops. Individuals who do not provide these documents can still attend the workshops, but they will need to pay a $300 registration fee because grant funding cannot be used to cover their registration fees.

Please select the program(s) you wish to attend.

Crucial Conversations® Training

__ Feb. 10-11, 2011 — University of Kansas Hospital, Westwood Campus

__ Feb. 18 and 25, 2011 — Saint Luke’s South

__ April 7-8, 2011 — Saint Luke’s Northland

__ April 13 and 27, 2011 — Saint Luke’s South

Influencer Training®

Staff is currently working on dates for 2011.

Crucial Confrontations® Training

Staff is currently working on dates for 2011.

Please make checks payable to The Health Alliance of MidAmerica. Mail this form and your payment to Janet Ruby, Kansas City Metropolitan Healthcare Council, 7015 College Blvd, Suite 150, Overland Park, KS 66211. Identify your name and the program dates you are attending on the check. The check must arrive no later than one week before the program.

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