Contact name:

Organization:

Mailing address:

County:

Telephone number:

Fax number:

Email address:

Topics of presentation:

CANHR Services Medi-Cal Nursing Home Residents' Rights Residential Care Rights

Elder Abuse Issues Elder Fiduciary Abuse Family Council Other:

Date of presentation:

Start time: End time:

For how many people? (20 Attendee Minimum)

Who is the audience? (consumers, professionals, etc.)

Location of presentation (name):

Location of presentation (address):

CANHR requests an honoraium of a minimum of $100 depending on travel distance, length of presentation and materials. Honorarium available an a sliding scale, depending on type of presentation and type of consumer audience.

Please check the appropriate box below.

Can Pay a minimum of $100 Honorarium