VIRTUAL SOCIAL SERVICE DESIGNEE TRAINING - 2021 Registration Form

Unique ID
Event Description*
Class Code*
Location Code*
Facility/Company*
Membership type
This field will be hidden in final version and is visible for testing purposes.
Membership*
- NNFA Member
- NALA Member
- NNFA and NALA Member
- Non-Member
Facility/Company Address*
Street Address Address Line 2 City State ZIP Code
Facility/Company Phone*
Email of Person Completing this Form*

Tuition and Fees
Non-Member Tuition and Fees*
Price: $598.00
Member Tuition and Fees*
Price: $299.00
Section Break
Total
$0.00

Social Security Number*
SSN Hidden*
A student’s Social Security number is required as a condition of enrollment. A student’s Social Security number constitutes an “educational record” under the Federal Educational Rights and Privacy Act (FERPA). That information will be disclosed only with the consent of the student or in those very limited circumstances when consent is not required by FERPA.
Name*
First Last
Home Address*
Street Address Address Line 2 City State ZIP Code
County*
Phone (Day)*
Phone (Evening)
E-mail Address
This is how we will send you information, so while not required, it is highly recommended!

Date of Birth*
Date Format: MM slash DD slash YYYY
Gender
- Male
- Female
Maiden Name
Race
Nebraska Resident
- Yes
College Credit
If requesting credit hours, must have high school transcript or equivalent on file with the Learning Center.
- Yes
Terms of Service*
Submission of this form indicates that I understand the following: My registration is complete and that I am accountable for the tuition and fees and subject to a grade in the courses listed. Should I officially drop, withdraw or cancel, any refund in tuition will be determined by the date I submit my request to the Learning Center. Failure to attend does not constitute an official drop/withdrawal.
The personal information is correct as shown; changes in the personal information must include the appropriate documentation.
Students enrolling in courses through the Nebraska Health Care Learning Center consent to being photographed and videotaped during educational sessions for the possible inclusion in educational materials published by the Learning Center, NHCF, NHCA, NNFA and NALA. It is the policy of the Nebraska Health Care Learning Center to provide equal opportunity and nondiscrimination in all admission, attendance and employment matters to all persons without regard to race, color, gender, religion, national origin, or
disability. Inquiries concerning the Nebraska Health Care Learning Center policies on equal opportunity and nondiscrimination should be directed to the Director of Nebraska Health Care Learning Center, 1200 Libra Drive, Suite 100, Lincoln, Nebraska 68512, phone 402-435-3551, fax 402-475-6289, or email nhclc@nehca.org.
- I agree to the Terms of Service

Copy Credit Cardholder Address from Facility/Company Address?
This address must match the Credit Card billing address.
- Yes
Copy Credit Cardholder Address from the Home Address?
This address must match the Credit Card billing address.
- Yes
Cardholder Address*
Street Address Address Line 2 City State ZIP Code
Cardholder's Email*
Cardholder Name*
Do you have a Scholarship or Coupon code?
- Yes
Coupon*
Total amount to be charged to Credit Card
$0.00
Credit Card

American Express
Discover
MasterCard
Visa
Card Number Expiration Date Security Code Cardholder Name

Review Your Selections
Click "Previous" to make changes. Click "Submit" to process your registration(s). {all_fields:exclude[58]}

Step 1 of 6 - Basic Information

Tuition and Fees

Section Break

Review Your Selections