Home Health Aides… The Strongest Hearts in Home Care & Hospice 2014 Home Health Aide Recognition Day Wednesday, November 12, 2014 8:30am—3:00pm Gibbs Hall at Suneagles Golf Course 2000 Lowther Drive Eatontown, NJ PARTICIPATING ORGANIZATIONS: HOME HEALTH AIDE RECOGNITION DAY 2014 Home Health Aides…. The Strongest Hearts in Home Care & Hospice Registration Form Organization ________________________________________________________________________ Contact Person ______________________________________________________________________ Address ____________________________________________________________________________ Phone _______________________________ Email _______________________________________ Award Recipients: Please list the names of all home health aides you would like to honor along with their corresponding level of recognition. You may only select one Rookie of the Year and one Home Health Aide of the Year per agency location. You may select multiple recipients for each “Years of Service” category. Name of Honoree Rookie of the Year* CHHA of the Year** YEARS OF SERVICE Must have completed number of years in selected category Less 5 10 15 20 25 30+ than 5 years years years years years years years * Rookie of the Year is awarded to an individual who has been a certified Home Health Aide for less than two years but has already exhibited excellence and growth in the role. ** Home Health Aide of the Year is awarded to the Certified Home Health Aide who has demonstrated excellence, leadership and compassion throughout their career. Please list any staff members who will be attending but who WILL NOT BE HONORED: ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ PLEASE NOTE: You may reserve seating for your organization by purchasing a full table (seating for 10). 12, 2014 We are unable to reserve seating for organizations that do not purchase a November full table. Home Health Aide Recognition Day HOME HEALTH AIDE RECOGNITION DAY 2014 Home Health Aides…. The Strongest Hearts in Home Care & Hospice Payment Form Organization: _______________________________________________________________________ Association Member (Please check all that apply) Home Care Association of NJ (HOMECARENJ) Home Care Council of New Jersey (HCCNJ) Home Health Services and Staffing Association of NJ (HHSSANJ) Leading Age New Jersey Hospice and Palliative Care Organization (NJHPCO) New Jersey Hospital Association (NJHA) Non- Member $92.00 / per person $920.00 / per table of 10 $130.00 / per person $1,300.00/ per table of 10 Registration Options: Total # of People Attending ________ ($92 Member/$130 Non-Member per person) OR Total # of Reserved Tables _________ ($920 Member/$1,300 Non-Member per table) Total Amount Due $ ________________________ PAYMENT Check: Check # _______________________________ Amount $__________________ (payable to Home Care Association of NJ) Credit Card: Visa MasterCard American Express Amount $__________________ There will be a 2.5% fee if paying by credit card: $____________ x 1.025 = $____________ Payment Amount Total Due Credit Card # __________________________________ CVV #_________ Expiration Date ________ Name on Card _____________________________ Signature ______________________________ Address on Card _____________________________________________________________________ Cancellations received on or before October 22, 2014 will be subject to a 25% administrative fee. There will be no refunds after October 22, 2014. Substitutions will be permitted but advance notice is preferred. Substitutions are not guaranteed inclusion in the program booklet. If you require special accommodations or dietary needs please call (732) 877-1100 or email [email protected] Please mail registration form and payment to: Home Care Association of NJ 485D Route 1 South, Suite 210, Iselin, NJ 08830 or fax to (732) 877-1101 Home Health Aide Recognition Day November 12, 2014 HOME HEALTH AIDE RECOGNITION DAY 2014 Home Health Aides…. The Strongest Hearts in Home Care & Hospice Tributes We offer your staff, clients, and their families an opportunity to write a short tribute which will be included in the keepsake book distributed at Home Health Aide Recognition Day. The tributes should be addressed to home health aides in general and not written to a specific person. Please email all tributes to Susan Manders [email protected] Please include the following information in your email: • Submitted By: Client/ Client’s Family (include their name) Staff (include their name) Organization (include their name) • Tribute details TRIBUTES must be received no later than October 17, 2014 for inclusion in the program book Contributions A highlight of the celebration is the gift raffle. Please help to make this year’s program special by contributing towards one of the many raffle prizes. Organizations that make a contribution will be recognized in the program book. Thank you for your generosity! Organization ________________________________________________________________________ Contact Person ______________________________________________________________________ Payment: Check: PAYMENT Check # _________________________ (payable to Home Care Association of NJ) Credit Card: Visa MasterCard American Express Amount $__________________ Amount $__________________ There will be a 2.5% fee if paying by credit card: $____________ x 1.025 = $____________ Payment Amount Total Due Credit Card # __________________________________ CVV #_________ Expiration Date ________ Name on Card _____________________________ Signature ______________________________ Address on Card _____________________________________________________________________ Home Health Aide Recognition Day November 12, 2014