Long-Term Care Orientation Form

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Important: This form is to be filled out by facilities/organizations only.

Individual employees should not complete this registration.

Facility Name

Facility Address

Address Line 1

City

State / Province / Region

Postal Code

Country

Dropdown

Facility Facility Notes/Comments

Number of Beds

This is the total number of beds in the facility. Please include all types of beds in this field.

Facility Contact Name

First

Last

The council will contact this person to provide course details. Please ensure that contact details are up-to-date.

Facility Contact Role

Facility Contact Email

Notes/Comments

Any additional details you would like to provide the council are welcome here.