Special Rates for the 2010 Breakfast for Brainiacs Audio Conferences

Site Coordinator's First and Last Name

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Agency Name

Address

Address 2

City

State

Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware D.C. Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code

Phone

Email Address

Audio Conferences: If you are signing up for 6 sessions, you can choose the 6 audioconferences that you plan to attend (these choices can be changed later.) If you are signing up for 1 year, please select each one.

January - 26 B4B Choosing Hope at the End of Life February 24 B4B - Pain Management and Substance Abuse March 24 B4B - Dying the Hard Way: Dealing with Terminal Restlessness April 20 B4B - First do no Harm: The Critical Nature of Personal and Professional Boundaries May 20 B4B - Advance Beneficiary Notice June 22 B4B - End of Life Care and African Americans July 29 B4B - Cost Effective Treatment of COPD August 19 B4B - Non-opioid Symptom Management September 28 B4B - Complicated Mourning November 18 B4B - Wound Care for Hospice Patients December 15 B4B - Burnout, Compassion Fatigue & Self Care

Site Registration: All you need to participate is a phone or speaker phone. A site coordinator from each participating agency must be registered using the form below. Materials such as the call instructions, roster, handouts, and evaluations will be sent to each site coordinator prior to the audioconference. It is the responsibility of each site coordinator to copy and distribute materials to the additional participants on the call. After the completion of the audioconference, the site coordinator is responsible for entering all participants on the on-line roster, and for providing participants with the on-line location for completing the evaluation for this course. Rosters and evaluations must be entered by Wednesday following the audioconference, or a $25 late fee will be charged. Continuing Education: The Carolinas Center for Hospice and End of Life Care is an Approved Provider of continuing nursing education by the North Carolina Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation. 1.0 contact hours are available for nurses. This program is also approved for social workers through the South Carolina Board of Social Work Examiners. 1.0 contact hours are available for all others. Certificates of completion will be mailed to each site coordinator after The Carolinas Center receives the roster and evaluations from your site coordinator.