Application for Admission
Which program would you like to apply to?
Keystone Advocacy Training Program
Encore Executive Development Community
First Name
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Last Name
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Email
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Mobile Phone
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Address
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City
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State
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Postal code
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Birthday (don't have to tell us the year... you can leave that set to the current year)
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Education & Experience
Please describe your educational background and list any degrees, certification, and licenses.
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Check all that apply.
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Doctor of Medicine (MD)
Doctor of Osteopathy
Physician Assistant
Nurse Practitioner
Registered Nurse
Licensed Practical Nurse / Licensed Vocational Nurse
Physical Therapist
Occupational Therapist
Speech Therapist
Pharmacist
Social Worker
Other
Please describe your work experience.
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Advocacy Goals
Why do you want to join the Keystone Advocacy Training Program or the Encore Executive Development Program?
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What are your career goals and how will our programs help you accomplish them?
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Business Name (leave blank if you don't have one yet)
Website address (leave blank if you don't have one yet)
Have you had any clients yet?
Yes
No
Not applicable
If you are a member of any Patient Advocacy Groups or Organizations, please list here. (leave blank if none)
Referral Details
How did you hear about us?
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Google
Other Search Engine
Facebook
Instagram
LinkedIn
TikTok
Other Social Media
Word of Mouth
Conference
Other
If you selected Conference, which one?
If you selected Word of Mouth, who can we thank?
Policies & Agreements
Refund Policy: I understand the registration fee is non-refundable.
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I agree
Forms Licensing Agreement: I have read the Forms Licensing Agreement and agree to its terms and will not share, sell, redistribute, or discuss the contents of the forms.
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I agree
Confidentiality Agreement: I have read the Confidentiality Agreement and agree to its terms. I understand that it protects both The Bridge Health Advocates, PLLC and me, the client.
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I agree
Service Agreement: I have read the Service Agreement and agree to its terms and conditions. I understand that it protects both The Bridge Health Advocates, PLLC and me, the client.
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I agree
Continuing Education Credit
I am a Board Certified Patient Advocate and would like to obtain continuing education credit for these courses through the Patient Advocate Certification Board
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Yes
No
I am a Registered Nurse and would like to obtain continuing education credit for the courses through the California Board of Registered Nursing.
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Yes
No
RN License Number And State (required for RN credit)
Acknowledgements
I understand that the purpose of this course is to create and enhance a personal health advocacy business and any training I receive through this course is for my own personal edification. I agree not to use this information in other ways. I will not resell, distribute, or use in my marketing.
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Yes
No
I understand that The Bridge Health Advocates will review my application and notify me if I am accepted. In some instances, a virtual meeting may be required before a decision is made.
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Yes
No
Submit Application