All-In Palliative Care Application Form

Welcome to the All-In Palliative Care: The Team Approach to LTC application form!

Due to demand, the application deadline has been extended to October 6, 2023 (11:59 PM ET).

Thank you for your interest in the All-In Palliative Care: The Team Approach to LTC Training Program!

Before completing this form, please ensure you meet the following criteria:

You are your LTC home’s Administrator or you are filling out this form on behalf of your Administrator
Your LTC home is located in Ontario
We will ask you for names and emails of your learners to register, however before the day of the training, you can swap out your learners as needed
Limited wage support of $250/learner is available if requested at registration

All applicants will receive an update on the status of their acceptance via email by October 13, 2023. If you have any questions, please contact a member of the Ontario CLRI at Bruyère team at ceolfund@bruyere.org or 613-562-6262, Ext. 1985.

Welcome to the All-In Palliative Care: The Team Approach to LTC application form! Application deadline: [Month Date], 2022 (11:59 PM ET).

Before completing this form, please ensure that you meet the following criteria:

Your home is involved in the Collaborative Project to Sustain a Palliative Approach to Care
You have read the All-In Palliative Care Information Package
You are your LTC home’s Administrator or you are filling out this form on behalf of your Administrator

Once you complete this form, you will automatically receive a copy of your submission. By September 2022, we will confirm your training date(s) and follow up with next steps on how your learners can enroll in the training. If you have any questions, please contact a member of the Ontario CLRI at Bruyère team at ceolfund@bruyere.org or 613-562-6262, Ext. 1985.

Long-Term Care Home Information

Home Name(Required)

Name(Required)

First Last

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Address

Hidden

Address Line 2

Hidden

City

Hidden

Province

Hidden

Postcode

Phone(Required)

Phone Ext.

Email(Required)

Enter Email Confirm Email

Job Title(Required)

Would you like to provide an alternate contact for your LTC home?(Required)

Yes

Alternate Contact Name(Required)

First Last

Alternate Contact Phone(Required)

Alternate Contact Phone Ext.

Alternate Contact Email(Required)

Enter Email Confirm Email

Alternate Contact Job Title(Required)

Training Attendance Information

The total number of interprofessional team members you plan to have attend this training:(Required)

Please enter a number greater than or equal to 3.

FOR YOUR REFERENCE: A list of interprofessional team members we recommend attend this training (response not required).

Each training session will include 10 to 30 learners. Would you like the learners from your LTC home to attend the virtual training program on the same date or be spread across multiple training dates?(Required)

One training date

Multiple training dates

How many learners from your LTC home would you like to have attend each training date?(Required)

Select your top 3 preferred training dates from the list provided below:(Required)

Tuesday, October 24, 2023

Wednesday, October 25, 2023

Thursday, October 26, 2023

Tuesday, October 31, 2023

Thursday, November 2, 2023

Tuesday, November 7, 2023

Thursday, November 9, 2023

Tuesday, November 14, 2023

Thursday, November 16, 2023

Tuesday, November 21, 2023

Wednesday, November 22, 2023

Thursday, November 23, 2023

Tuesday, November 28, 2023

Wednesday, November 29, 2023

Thursday, November 30, 2023

Tuesday, December 5, 2023

Wednesday, December 6, 2023

Thursday, December 7, 2023

Learner Information

Learner Information(Required)

You may either include your learner information directly in this application form or upload one Word/Excel file that contains this information. To add a row, press the plus sign that's next to the right most column.

Name

Role

Wage Support (Yes/No)

Max. file size: 256 MB.

Training and Accessibility Requirements

Each learner needs to connect on their own screen. A tablet, laptop or computer connected to Wifi, audio and webcam is required for each team member to attend the training. Team members cannot attend together using one screen.

Click here to indicate that your home is able to meet this requirement

Please indicate if there are any barriers to you meeting these training requirements (e.g. limited access to computers, no webcams available, insufficient space to train learners in your LTC home, etc.). Your feedback will help the Ontario CLRI at Bruyère team understand what barriers exist and ways we may help to allow your team to access this training.

Do any of your team members require additional accessibility accommodations to make their learning experience barrier-free? (E.g. the presence of a sign language interpreter, printed materials, etc.). Your feedback will help the Ontario CLRI at Bruyère team ensure that this training is accessible to all interested interprofessional team members.

Is your LTC home comfortable receiving course-related materials via mail?

Yes

Motivation to Apply

How did you hear about this learning opportunity?

Ontario CLRI newsletter/email

Ontario CLRI website

Ontario CLRI social media

A colleague, friend or family member

OLTCA

Comments

This field is for validation purposes and should be left unchanged.

Resources

Long-Term Care Home Information

Training Attendance Information

Learner Information

Training and Accessibility Requirements

Motivation to Apply

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