IHA WIO Recruitment Campaign Participation Form

Organization Name *

Contact Name *

First

Last

Contact Email Address *

In order for your organization to participate in the Caring Gene® campaign, your organization must commit to provide baseline and ongoing data related to your organization's recruitment activities during the course of the campaign. If you agree, please click YES. If you respond NO, your organization will not be included. *

Yes
No

Organization Name (as you want it to appear on the campaign's landing page)

Organization Address (as you want it to appear on the campaign's landing page)

Address Line 1

Address Line 2

City

State

Zip Code

County the Organization is Located In

Organization Phone Number (as you want it to appear on the campaign's landing page)

Organization CAREER PAGE/JOB LISTING URL (as you want it to appear on the campaign's landing page)

If you do not have a Career Page/Job Listing on your website, please provide your main URL.

Does your organization offer certification training for CNAs, HHAs and/or PCAs? Check all that apply.

CNAs
HHAs
PCAs

If your organization offers certification training, please provide the CERTIFICATION TRAINING URL (as you want it to appear on the campaign landing page)

If you do not have a Certification Training page on your website, your main URL will be used.

Caring Gene® Recruitment Campaign Participation Form