H o m e

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 susan@homecarenj.org
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 susan@homecarenj.org
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