Agency
(if registering as an individual not associated with a home health agency please state what agency you will be working with to provide your preceptor)

Address

City, State, Zip code

Phone       Fax

Student Name

E-mail

 

Preceptor Name

E-mail

 

Tech Support name 

E-mail

Enter course start date below:
(Cannot be less than two weeks from today)

Select below:
Staff of HCAC Member Agency or designated partner or individual
not associated with a home health agency $475 per student
Non-Member Agency $875 per student

Payment
  VISA MasterCard American Express Check payable to HCAC (due within 7 days) Purchase Order

Cardholder's name

Card number

Exp. date

Purchase Order Number

By submitting this registration, this agency agrees to: 

·          Assign an on-site preceptor (mentor) who will assist the student in accessing required agency materials and sign off on the student competencies;

·          Provide on-site computer technical support, and

·          Make available text books, policies and procedures, home health care reference books and articles.

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