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Nursing Home Staff Registration

By joining the Campaign, nursing home staff can help the nursing home achieve its goal of improving the quality of care and quality of life for residents and staff. If you are an employee of a nursing home or a consultant, register by using this form to become a member of the Campaign. If you are a NURSING HOME ADMINISTRATOR who is currently the administrator of record for a nursing home, please complete the Nursing Home Registration on the Advancing Excellence website. Other licensed administrators may join here.

* indicates required fields

Contact Information¹
*First name:
*Last name:
Name of Nursing Home:
*City:
*State where you work:
Email Address:
*Re enter Email Address:
I would like to receive communication about the Campaign.
I would like the LANE (the statewide group working to Advance Excellence) to contact me about how I can help. Please give them my email address. What is a LANE?
¹ Your contact information will not be shared for marketing or other purposes not directly related to the campaign.
*I am best described as (click all that apply):
	Certified or Licensed Nurse Assistant
	Licensed Practical or Vocational Nurse
	Registered Nurse
	MDS Coordinator
	Staff Development Coordinator
	Medicare Coordinator
	Quality Improvement Nurse or Coordinator
	Director of Nursing
	Health Information Manager/Medical Records
	Advanced Practice Nurse ( Nurse Practitioners and Clinical Nurse Specialists)
	Rehabilitation Therapist (physical, speech, occupational, recreation)
	Social Worker
	Activities Director or Staff
	Nutrition, Dietary or Food Service Staff
	Environmental Services Staff (housekeeping, grounds, maintenance, laundry)
	Administrative and Support Staff
	Clinical Consultant (dietician, pharmacist, etc.)
	Medical Director
	Physician
	Physician’s Assistant
	Other nursing home staff
*I want to help in the following ways (check all that apply):
	My nursing home has joined the campaign and I want to help achieve selected goals.
	Ask my nursing home to join the campaign and work to help achieve the selected goals.
	Have discussions about the Campaign at professional association and union meetings.
	Share information about the Campaign with resident and family councils.
	Learn about the eight goals and share this information with others.
	Other:
By clicking the "I Accept" button below, I voluntarily agree to be involved in working toward the goals of the Advancing Excellence in America’s Nursing Homes campaign. I understand that my contact information will not be shared for marketing or other purposes not directly related to the campaign.