Nurse Leadership Council Online Application

Name of Applicant

Organization

Organization Description

Multi-site Provider

Single-site Provider

Other...

Provider Type (check all that apply)

CCRC

SNF

AL/PC

HCBS

LIFE

Other...

Position within Organization

Email Address

Phone number

What professional license(s) does the nominee hold?

LPN

Other...

How long have you worked at your organization?

How long have you worked in the aging services field?

Please list and provide dates if you graduated from the LeadingAge PA Fellows in Leadership program or LeadingAge National Leadership Academy

Please list any LeadingAge PA committees or task forces you have participated in over the past 5 years

What special expertise do you have in terms of potential service on the taskforce?

Regulations

Technology

HCBS

Assisted Living

Skilled Care

Personal Care

Other...

Please share a Statement of Intent: why would you like to be considered for the Nurse Leadership Council?

Upload your resume and/or bio below

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