Application Date

MM

DD

YYYY

Select Your Preferred Cohort

Currently enrolling cohort

Please contact me about a future cohort

Name of Person Applying *

First Name

Last Name

Best Phone Number for Contact Peson *

(###)

###

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Address of the Facility/Community

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

License Type (Assisted Living or Residential Care): *

Assisted Living Facility (ALF)

Residential Care Facility (RCF)

Skilled Nursing Facility (SNF)

Program for All-Inclusive Care for the Elderly (PACE)

Continuing Care Retirement Community (CCRC)

Memory Care Endorsement? *

Please check one box

Yes

No

i) Does Your Community Accept Medicaid as Payment for Any Current Residents? *

Please check one box

Yes

No

j) Is Your Community For-profit, Non-profit, or Other?: *

Please check one box

For-profit

Non-profit

Other

Attendance at weekly LiveWell training events over a 15-week period: *

Please acknowledge your agreement to the following by checking both boxes below: 1) The Administrator must attend the first four sessions on leadership. After the first session, Administrator attendance is optional, but in our experience the more support the Administrator shows by learning alongside staff, the more successful the community will be. Any staff person who is responsible for mentoring or training others should be present for the first leadership sessions. 2) A team of 3-5 or more must attend all remaining sessions. Select your team based on who is a formal or informal leader. They can come from any area, including activities, caregiving, housekeeping, dining, maintenance, or nursing. They are people who have the respect of their peers, often people who have been there the longest, and are open to change.

The administrator and key leaders will attend the first four sessions.

A team of 3-5 must attend all remaining 11 sessions.

The Administrator must be a champion for their LiveWell team. *

Although we don’t require the administrator to attend all the training events, the administrator must be a cheerleader, a supporter, and a champion of the team that is implementing LiveWell. The trainer/coaches will offer guidance and support to administrators on how to be a champion. If the administrator is not fully on board, the LiveWell Method will not work.

The Administrator agrees to champion and support LiveWell

The Administrator also agrees to the following: *

Please acknowledge your agreement by checking all boxes:

To encourage all team members to complete a brief online survey at beginning and end of the collaborative

To submit a separate letter of support from the CEO, owner, or regional director

To submit a signed participation agreement

Images, interviews, testimonials, and excerpts from recorded meetings may be used by the LiveWell staff to demonstrate program benefits