Application for the Ostomy Care Associate Program

Please complete the form below and click the “Submit” button. A payment of $975 for the course should be mailed to: Heale Wound Care, PO Box 323, Saxtons River, VT 05154.

Name

First Name

Last Name

Date

YYYY

Location facility/agency

Floor/type of unit

How long have you been qualified?

State and license #

Email (must be the same you use to access the OCA program)

Mobile phone number

(###)

###

####

Preferred phone number, if different

(###)

###

####

Name & email of your local WOC nurse or supporting Licensed Independent Provider

Name & email of your manager

To participate, you must confirm that you:

1) Have good access to a computer to view the course and it is capable of streaming video.

Yes

Confirm that you:

2) Are able to attend all mandatory sessions.

Yes

Thank you for your interest in this program! You will receive notification of acceptance within 2 weeks of your application being received. Confirmation of your place will be emailed on receipt of full payment. Please write a short narrative below explaining what interests you about ostomy care. How will this program benefit you and your unit, facility, or agency? What do you expect to take away from this training?

OCA Program Application

Application for the Ostomy Care Associate Program

Please complete the form below and click the “Submit” button. A payment of $975 for the course should be mailed to: Heale Wound Care, PO Box 323, Saxtons River, VT 05154.

Heale Wound Care

Links to other sites:

WOCN News (Wound, Ostomy, and Continence Nurses Society)

WOC Nurse Certification Board

Anatomical Ostomy Aprons

Mesothelioma.net

Haiti Health Care Project