Nursing Pledge - Enrollment - Ontario Centres for Learning, Research, and Innovation in Long-Term Care

Nursing PLEDGE Enrollment Agreement Form

Through the Nursing Partnership for Learning, Employment, Development, Growth and Experience Program (Nursing PLEDGE) program, homes are eligible for various types of funding to support starting up, implementing, delivering, and evaluating a nursing mentorship program. Please complete the following Enrollment Agreement Form to participate in Nursing PLEDGE.

The deadline to enroll in the program is September 30th, 2026 (for up to 100% of available funding). LTC homes that enroll between October 1st, 2026 and January 27th, 2027 will only receive up to 50% of annual funding.

Please note that this year’s funding commitment is up to $49,000. Please see below for additional details and reporting requirements.

Section 1: Long Term Care Home Name

LTC Home(Required)

If you are unable to select your LTC Home from the list, please contact us before continuing.

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Home Name

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Ontario Health Region

Section 2: Program Contact Information

Please provide the requested contact information below. At minimum, homes are required to name a Primary Contact, Secondary Contact, and Finance Individual for Nursing PLEDGE team members to connect with throughout the program year.

Note: LTC homes are eligible to receive mentorship coordination funding to support the administrative elements of the mentorship program. This includes support for designing the mentorship program or enhancing your existing program, scheduling, identifying mentors and mentees, and documentation of processes and evaluation of results.

Primary Contact Contact Information(Required)

First Last

Job Title(Required)

Email address(Required)

Phone(Required)

Phone extension

Briefly describe this individual’s role with respect to planning and/or managing the mentorship program within your home.(Required)

Secondary / Alternate Contact Information(Required)

First Last

Job Title(Required)

Email address(Required)

Phone(Required)

Phone extension

Briefly describe this individual’s role with respect to planning and/or managing the mentorship program within your home.(Required)

Please select one of the following options:(Required)

Our Mentorship Coordinator is the Primary Contact listed above

Our Mentorship Coordinator is the Secondary / Alternate Contact listed above

Our Mentorship Coordinator is someone else

We do not have a Mentorship Coordinator in our LTC home

Mentorship Coordinator Contact Information(Required)

First Last

Job Title(Required)

Email address(Required)

Phone(Required)

Phone extension

Briefly describe this individual’s role with respect to planning and/or managing the mentorship program within your home.(Required)

Please select one of the following options:(Required)

Our Finance Individual is the Primary Contact listed above

Our Finance Individual is the Secondary / Alternate Contact listed above

Our Finance Individual is someone else

Finance Individual Contact Information(Required)

First Last

Job Title(Required)

Email address(Required)

Phone(Required)

Phone extension

Briefly describe this individual’s role with respect to planning and/or managing the mentorship program within your home.(Required)

Please select one of the following options:(Required)

Our Corporate Contact is the Primary Contact listed above

Our Corporate Contact is the Secondary / Alternate Contact listed above

Our Corporate Contact is someone else

We do not have a Corporate Contact in our LTC home

Corporate Contact Information(Required)

First Last

Job Title(Required)

Email address(Required)

Phone(Required)

Phone extension

Briefly describe this individual’s role with respect to planning and/or managing the mentorship program within your home.(Required)

Section 3: Mentorship Program Information

Please respond to the following questions related to your home’s Nursing mentorship program. Your responses will help the Nursing PLEDGE team understand your home’s current situation.

Do you currently have a formal mentorship program within your Long Term Care home?(Required)

Yes

How many Mentors do you currently have?(Required)

1-3

4-6

7 or more

Please select the nursing category of current mentors. Check all that apply.(Required)

Nurse Practitioner

Registered Nurse

Registered Practical Nurse

Indicate what types of mentorship activities your LTC home currently hosts. Check all that apply.(Required)

Onboarding

Role Coaching

Clinical skill development

Leadership training

Other (please specify)

Other:

What factors are limiting your LTC home’s capacity to implement a mentorship program?(Required)

How will Nursing PLEDGE funds contribute to resolving these challenges?(Required)

Section 4: Requested Resource Information

In addition to funding, Nursing PLEDGE will be developing various resources to help you start, implement, deliver, and evaluate your mentorship program. Mentor resources can be found at clri-ltc.ca/nursing-pledge/resource-centre/.

What additional types of resources would you find beneficial for supporting your nursing mentorship program?

Section 5: Funding Agreement

Please read the following section carefully before indicating your agreement.

Nursing PLEDGE Coordination Funds

Homes may receive $10,000 to support nursing mentorship program coordination-related activities. If you choose to accept these funds, they will be deposited into your home’s account within 90 days of submitting this Agreement Form and must be spent by March 31st, 2027. Please note that the $10,000 Nursing PLEDGE Coordination Funds are included in the (potential) $49,000, funding.

Would your LTC home like to register for these mentorship coordination funds?(Required)

Yes

Mentorship Backfill Funding Requirements

Homes may receive up to $39,000 in Mentorship Backfill funding awarded in two installments

First installment $19,500:

Register a minimum of 1 mentor;
Mentor participation in CoP;
Indicate a willingness to participate in mentor modules once available;
Begin/ enhance mentorship program development within the home;
Participate in Nursing PLEDGE evaluation program elements

Second installment $19,500:

Mentor/ Mentee participation in CoP;
Each mentor/ mentee completes mentor modules;
Continued registration of additional mentors and/ or mentees;
Continued in-home mentorship program development and implementation for registered mentees;
Participation in Nursing PLEDGE evaluation program elements

Would your LTC home like to register for these funds?(Required)

Yes

Additional information:

Mentorship Backfill Funds will be deposited into your home’s account in two separate installments, once program funding requirements are met for each installment (as identified above).

Homes will also be required to participate in the Nursing PLEDGE Evaluation program which may include ( but is not limited to) the following:

Baseline evaluation
Mid Year reports
Year end reports
Pre and Post Survey for Mentors
Pre and Post Survey for Mentees

Upon submission of this Enrollment Agreement Form, you will receive an email confirmation that will include a unique link that your home will use throughout the Nursing PLEDGE program to register all mentors and mentees into the program.

Nursing PLEDGE Year	LTC Home Nursing PLEDGE Enrollment Dates	Mentor/ Mentee Registration Dates
Year 1 (Jan – March 31, 2026)	Jan – March 27, 2026	Jan – March 27, 2026
Year 2 (April 1, 2026 – March 31, 2027)	Previously enrolled LTC homes Nursing PLEDGE program will confirm LTC home interest in program renewal and funding. Upon confirmation, funding requirements will be applied to in year payments. New enrollments LTC Homes not previously enrolled can do so up to Sept 30th, 2026 (for up to 100% of available funding; or between Oct 1 – January 22, 2027 (for up to 50% of annual funding)	April 1 – Jan 22, 2027
Year 3 (April 1 2027 – March 31, 2028)	Previously enrolled LTC homes Nursing PLEDGE program will confirm LTC home interest in program renewal and funding. Upon confirmation, funding requirements will be applied to in year payments. New enrollments LTC Homes not previously enrolled can do so up to Sept 30th, 2027 (for up to 100% of available funding); or between Oct 1 – Jan 21, 2028 (up to 50% of annual funding)	April 1 – Jan 21, 2028

All mentors and mentees that your home wishes to register in the program must be in the system by January 22, 2027.
All funds must be spent by March 31st, 2027.

Acknowledgments

Nursing PLEDGE Coordination Funds Acknowledgments

Untitled(Required)

I acknowledge that the $10,000 Nursing PLEDGE Coordination Funds will be used to support Mentorship Program Coordination-related activities within my home.

Untitled(Required)

I acknowledge that the $10,000 Nursing PLEDGE Coordination Funds need to be spent by March 31st, 2027.

Untitled(Required)

I acknowledge that I will be required to participate in the Nursing PLEDGE Mentorship Program Evaluations and a Final Funding Report.

Mentorship Backfill Funds Acknowledgments

Untitled(Required)

I acknowledge that the Mentorship Backfill Funds my home receives will be used to support mentors in their effort to provide dedicated mentorship, completion of mentorship education, and participation in Nurse Mentor Community of Practice.

Untitled(Required)

I acknowledge that Mentors and Mentees registered for Backfill Funds meet the eligibility criteria ( as stated on the registration form).

Untitled(Required)

I acknowledge that all Mentorship Backfill Funds my home receives will be spent by March 31st, 2027.

Untitled(Required)

I acknowledge that I will be required to participate in the Nursing PLEDGE Mentorship Program Evaluations and a Final Funding Report.

Enrollment

Nursing PLEDGE Enrollment Agreement Form

Section 1: Long Term Care Home Name

Section 2: Program Contact Information

Section 3: Mentorship Program Information

Section 4: Requested Resource Information

Section 5: Funding Agreement

Acknowledgments

Do you have questions about the program?