LEADERSHIP CERTIFICATE PROGRAM IN-PERSON COURSE
APPLICATION FOR PRIVATE COURSE INSTRUCTION
Please complete this application to host the NAMSS Leadership Certificate Program In-Person course at your facility, State Association or Chapter and return to the address belowat leastthree months prior to when you would like to host the course. Once submitted, this application will be sent for review by the NAMSS Education Committee. Courses will be scheduled based on order of receipt and instructor availabilitywithin two weeks of receiving the application.
Organization Name: Click or tap here to enter text.
Contact Name: Click or tap here to enter text.
Contact Email: Click or tap here to enter text.
Phone: Click or tap here to enter text.Fax: Click or tap here to enter text.
Complete Mailing Address for Organization: Click or tap here to enter text.
Preferred Month/Date for Leadership Certificate Program In-Person Course: Click or tap here to enter text.
Please check the following boxes, sign and date the form below to acknowledge pre-requirements for the NAMSS Leadership Certificate Program In-Person Course.
☐ Organization agrees to 2-Day Leadership Certificate Program In-Person Course educational model.
☐ Organization agrees to cover the following fees:
•$1,000 Licensing Fee to NAMSS
•$100 course material fee (per participant)to NAMSS
•$1,500 per instructor honorarium (two instructors required)
☐ Cover costs of lodging, per diem and travel to/from course location for NAMSS Instructor(s)
☐ Organization agrees to manage facility logistics, registration, and Audio-Visual materials needed for course and assume all expenses associated with course logistics, registration and Audio-Visual.
☐ Organization agrees to provide one laptop, LCD projector, screen and two flip charts for course meeting room.
☐ NAMSS Instructors will be scheduled and confirmed by NAMSS, based on availability.Organization can make requests which will be honored whenever possible.
☐ Organization agrees to designate an On-Site Coordinator who will:
•Serve as the on-site liaison to NAMSS Instructor(s) and registered participants;
•Check in participants; and
•Provide volunteers to serve as room monitors to assist the instructor(s) during the course.
By signing and returning this Application of Interest to NAMSS, I signify that the organization, ______, understands and agrees to all the pre-requirements as written. Please note that courses will be scheduled based on order of receipt and instructor availability.
______
Name Date
Thank you for submitting your application! Please return this form to:
NAMSS
Education Department
2025 M Street, NW Suite 800
Washington, DC20036
PHONE: 202-367-2427
FAX: 202-367-2116