HBA Fellowship Registration - NorthStar Network

Prefix

Name *

First

Last

Suffix ex: MD, PhD, RN, Other

Email *

Work Phone *

Mobile Phone *

Address Line 1

Address Line 2

City

State

Zip Code

Headshot

Gender *

Male
Female
Other

Preferred Pronoun

He/Him
She/Her
They/Them
Xe/Xem

Race * $_POST[reg][race]=

American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Others

Accreditation Requirements *

None
ACHE Credits - Healthcare Management
CPE Credits - Accountants
CEU Credits - Long Term Care Administrators
CEU Credits - Nurses

How many credits do you need for year 2024? *

Employment

Job Title *

Current Employer *

Address Line 1

Address Line 2

City

State

Zip Code

Please describe your current role

How did you hear about the HBA Fellowship Program

Requirements

Participants are required to:

Attend and actively participate in all of the workshops and complete any required pre-work.
In-Person attendance is strongly preferred to maximize the value of the program to the individual Fellow as well as to classmates. Zoom will be offered for virtual attendance on an occasional, exception basis.
Participants who fail to fulfill their obligations will be asked to withdraw from the program. Fees will not be refunded once registered.
Please attach a personal photo headshot (above) that can be included on the graduation plaque and the class list. If you prefer to opt out and not be included please contact us.
Please provide any dietary restrictions and food allergies
Please indicate how you would like your name to be printed on your name badge.
Please tell us what you hope to get out of the Fellowship Program
I agree to these requirements
I give permission for NorthStar Network to use my name, testimonial and/or photo for promotional purposes. (Optional)

Employer/Sponsor Commitment (If Applicable)

This application has the approval of this organization and the applicant has our full support, if accepted, to devote the time required to participate in the program.

Full financial sponsorship of a candidate is $6,000 and needs to be paid by February 3, 2024. I understand the tuition is non-refundable.

Employer/Sponsor Organization (if applicable)

Contact Name

Contact Title

Payment Information - $6,000

Payment Method *

Credit Card
Purchase Order
Invoice Me
I Already Paid

PO Number

PO Name

PO Email

PO Phone Number

Address Line 1

Address Line 2

City

State

Zip Code

We will send an invoice to:

Invoice Number

Contact Name

Contact Email

Contact Phone Number

Address Line 1

Address Line 2

City

State

Zip Code

Registration for 2024 HBA Fellowship Program

Selection Criteria

Application Instructions

Contact Information

Employment

Requirements

Employer/Sponsor Commitment (If Applicable)

Payment Information - $6,000

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