Culture Change Conference Registration

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0><tr> <td valign="top" colspan=2 height=160 BGCOLOR="#006699" TEXT="#080000" background="16d00a03.jpg"> <div> <I><B>V</B></I><FONT SIZE="6" COLOR="#000080" FACE="Verdana" ><I><B>oices</B></I></FONT><FONT SIZE="6" COLOR="#000080" FACE="TimesRoman" ><I><B> </B></I></FONT><FONT SIZE="5" COLOR="#000080" FACE="Verdana" ><I><B>for Quality Care (LTC), Inc.</B></I></FONT></div> <bR> <div> <B>P.O. Box 2251, Leonardtown, MD 20650</B></div> <div> <B>1-888-600-2375</B></div> <div> </div> </td> </tr><tr> <td valign="top" width=210 BGCOLOR="#FFCC66" TEXT="#080000" background="178cae83.jpg"> <div> <B> <TABLE BORDER="2" CELLPADDING="2" CELLSPACING="1" WIDTH="177" BORDERCOLORLIGHT="#000099" BORDERCOLORDARK="#000099" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 608 WIDTH="165"><div> <B>Website Navigation Panel</B></div> <div> Click on the text below to go to other pages in our website<FONT SIZE="2" COLOR="#000000" FACE="Arial" ><B>.</B></FONT></div> <div> <A HREF="index.htm" TARGET="_top" TITLE="Voices for Quality Care"><U><B>Home</B></U></A></div> <div> <A HREF="id45.htm" TARGET="_top" TITLE="About Voices"><U><B>About Voices</B></U></A></div> <div> <A HREF="id59.htm" TARGET="_top" TITLE="Culture Change"><U><B>Culture Change</B></U></A></div> <div> <A HREF="id72.htm" TARGET="_top" TITLE="Beth Bakers Book"><U><B>Beth Baker's Book</B></U></A></div> <div> <A HREF="id49.htm" TARGET="_top" TITLE="Nursing Home Staffing in Maryland"><U><B>Nursing Home Staffing in Maryland</B></U></A></div> <div> <A HREF="id48.htm" TARGET="_top" TITLE="Nursing Home Deficiency Lists"><U><B>Nursing Home Deficiency Lists</B></U></A></div> <div> <A HREF="id56.htm" TARGET="_top" TITLE="Laws and Regulations"><U><B>Laws and Regulations</B></U></A></div> <div> <A HREF="id47.htm" TARGET="_top" TITLE="Related Websites"><U><B>Related Websites</B></U></A></div> <div> <A HREF="id43.htm" TARGET="_top" TITLE="Contact Us"><U><B>Contact Us</B></U></A></div> <div> <A HREF="id46.htm" TARGET="_top" TITLE="Membership Application"><U><B>Membership Application</B></U></A></div> <div> <A HREF="id53.htm" TARGET="_top" TITLE="Directions to Our Meetings"><U><B>Directions to Our Meetings</B></U></A></div> <div> <A HREF="id52.htm" TARGET="_top" TITLE="Voices ByLaws"><U><B>Voices ByLaws</B></U></A></div> <div> <A HREF="id54.htm" TARGET="_top" TITLE="Terms of Service"><U><B>Terms of Service</B></U></A></div> <div> <A HREF="id55.htm" TARGET="_top" TITLE="Privacy Policy"><U><B>Privacy Policy</B></U></A></div> <div> <A HREF="id176.htm" TARGET="_top" TITLE="Maryland Ombudsman Program"><U><B>MD Ombudman Program</B></U></A></div> <div> <A HREF="id76.htm" TARGET="_top" TITLE="Donation"><U><B>Donate to Voices</B></U></A></div> </tD> </tR> </TABLE></B></div> <bR> </td> <td valign="top" height=320 BGCOLOR="#FFFFFF" TEXT="#080000"> <bR> <bR> <div>  <html> <head> <title>Seminar Registration</title> <meta name="generator" content="Created Using Yahoo! PageBuilder 2.61.90"> <meta name="keywords" content="Culture Change Seminar"> </head> <body bgcolor="#CCFFFF" link="#0000FF" vlink="#FF0000" text="#000000" > <table border=0 cellspacing=0 cellpadding=0 width=650 align="center"> <tr valign="top" align="left"> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=2></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=13></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=3></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=7></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=15></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=4></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=1></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=30></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=16></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=1></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=45></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=7></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=1></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=9></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=1></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=2></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=9></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=4></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=2></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=9></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=3></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=39></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=15></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=3></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=11></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=24></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=15></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=20></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=13></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=1></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=9></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=15></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=3></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=22></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=134></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=26></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=48></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=6></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=1></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=7></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=18></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=3></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=2></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=29></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=2></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=1></td> </tr> <tr valign="top"> <td colspan=46 height=17></td> </tr> <tr valign="top"> <td colspan=9 height=115></td> <td align="center" colspan=29 rowspan=1 width=497><b><font color="#000099" face="Helvetica" size="+1"><span style="font-size:18">Second Culture Change Conference--Quality of Life<br>April 29, 2007<br></span></font></b><b><font color="#000099" face="Helvetica"><span style="font-size:14">Greater Waldorf Jaycees Community Center<br>3092 Crain Highway (Rt. 301)<br>Waldorf, MD</span></font></b></td> <td colspan=8 height=115></td> </tr> <tr valign="top"> <td colspan=46 height=47></td> </tr> <tr valign="top"> <td colspan=1 height=114></td> <td colspan=43 rowspan=1 width=646><b><font color="#000099" face="TimesRoman"><span style="font-size:14">This conference includes a light lunch.  Cost is $10, except there is no charge for nursing home or assisted living facility residents. Space is limited so please register early. If you wish to attend, please provide the following information. We'll provide detailed driving directions to the conference.<br><br>Submit a completed form for each person who wishes to attend.</span></font></b></td> <td colspan=2 height=114></td> </tr> <tr valign="top"> <td colspan=46 height=26></td> </tr> <tr valign="top"> <td colspan=14 height=5></td> <form method=post action="http://us.1.p7.webhosting.yahoo.com/forms?login=voicesforqualitycare"> <td colspan=26 rowspan=2 width=442><INPUT type=TEXT size=54 maxlength=80 name="Name for Waldorf Culture Change Conference" value="" ></td> <td colspan=6 height=5></td> </tr> <tr valign="top"> <td colspan=7 height=17></td> <td align="right" colspan=5 rowspan=2 width=99><b><font color="#000099" face="Helvetica"><span style="font-size:14">Name</span></font></b></td> <td colspan=2 height=17></td> <td colspan=6 height=17></td> </tr> <tr valign="top"> <td colspan=7 height=2></td> <td colspan=34 height=2></td> </tr> <tr valign="top"> <td colspan=46 height=12></td> </tr> <tr valign="top"> <td colspan=14 height=4></td> <td colspan=26 rowspan=2 width=442><INPUT type=TEXT size=54 maxlength=25 name="Address 1" value="" ></td> <td colspan=6 height=4></td> </tr> <tr valign="top"> <td colspan=7 height=18></td> <td align="right" colspan=5 rowspan=2 width=99><b><font color="#000099" face="Helvetica"><span style="font-size:14">Address 1</span></font></b></td> <td colspan=2 height=18></td> <td colspan=6 height=18></td> </tr> <tr valign="top"> <td colspan=7 height=1></td> <td colspan=34 height=1></td> </tr> <tr valign="top"> <td colspan=46 height=13></td> </tr> <tr valign="top"> <td colspan=14 height=3></td> <td colspan=26 rowspan=2 width=442><INPUT type=TEXT size=54 maxlength=25 name="Address 2" value="" ></td> <td colspan=6 height=3></td> </tr> <tr valign="top"> <td colspan=7 height=19></td> <td align="right" colspan=5 rowspan=1 width=99><b><font color="#000099" face="Helvetica"><span style="font-size:14">Address 2</span></font></b></td> <td colspan=2 height=19></td> <td colspan=6 height=19></td> </tr> <tr valign="top"> <td colspan=46 height=14></td> </tr> <tr valign="top"> <td colspan=14 height=2></td> <td colspan=26 rowspan=3 width=442><INPUT type=TEXT size=54 maxlength=25 name="City" value="" ></td> <td colspan=6 height=2></td> </tr> <tr valign="top"> <td colspan=7 height=19></td> <td align="right" colspan=5 rowspan=1 width=99><b><font color="#000099" face="Helvetica"><span style="font-size:14">City</span></font></b></td> <td colspan=2 height=19></td> <td colspan=6 height=19></td> </tr> <tr valign="top"> <td colspan=14 height=1></td> <td colspan=6 height=1></td> </tr> <tr valign="top"> <td colspan=46 height=14></td> </tr> <tr valign="top"> <td colspan=14 height=1></td> <td colspan=12 rowspan=3 width=122><INPUT type=TEXT size=14 maxlength=25 name="State" value="" ></td> <td colspan=20 height=1></td> </tr> <tr valign="top"> <td colspan=7 height=19></td> <td align="right" colspan=5 rowspan=1 width=99><b><font color="#000099" face="Helvetica"><span style="font-size:14">State</span></font></b></td> <td colspan=2 height=19></td> <td colspan=20 height=19></td> </tr> <tr valign="top"> <td colspan=14 height=2></td> <td colspan=20 height=2></td> </tr> <tr valign="top"> <td colspan=46 height=14></td> </tr> <tr valign="top"> <td colspan=7 height=19></td> <td align="right" colspan=5 rowspan=1 width=99><b><font color="#000099" face="Helvetica"><span style="font-size:14">Zip</span></font></b></td> <td colspan=2 height=19></td> <td colspan=11 rowspan=2 width=98><INPUT type=TEXT size=11 maxlength=25 name="Zip" value="" ></td> <td colspan=21 height=19></td> </tr> <tr valign="top"> <td colspan=14 height=3></td> <td colspan=21 height=3></td> </tr> <tr valign="top"> <td colspan=46 height=13></td> </tr> <tr valign="top"> <td colspan=2 height=1></td> <td align="right" colspan=10 rowspan=2 width=129><b><font color="#000099" face="Helvetica"><span style="font-size:14">Phone (required)</span></font></b></td> <td colspan=34 height=1></td> </tr> <tr valign="top"> <td colspan=2 height=18></td> <td colspan=2 height=18></td> <td colspan=15 rowspan=2 width=170><INPUT type=TEXT size=20 maxlength=25 name="Phone" value="" ></td> <td colspan=17 height=18></td> </tr> <tr valign="top"> <td colspan=14 height=4></td> <td colspan=17 height=4></td> </tr> <tr valign="top"> <td colspan=46 height=9></td> </tr> <tr valign="top"> <td colspan=21 height=3></td> <td align="right" colspan=21 rowspan=3 width=433><b><font color="#000099" face="Helvetica"><span style="font-size:14">Do not include phone number in public list of those attending</span></font></b></td> <td colspan=4 height=3></td> </tr> <tr valign="top"> <td colspan=15 height=15></td> <td colspan=3 rowspan=1 width=15><INPUT type="checkbox" name="Do not include phone number" value="true" ></td> <td colspan=3 height=15></td> <td colspan=4 height=15></td> </tr> <tr valign="top"> <td colspan=21 height=8></td> <td colspan=4 height=8></td> </tr> <tr valign="top"> <td colspan=46 height=16></td> </tr> <tr valign="top"> <td colspan=3 height=2></td> <td align="right" colspan=10 rowspan=2 width=127><b><font color="#000099" face="Helvetica"><span style="font-size:14">Email (required)</span></font></b></td> <td colspan=33 height=2></td> </tr> <tr valign="top"> <td colspan=3 height=22></td> <td colspan=2 height=22></td> <td colspan=15 rowspan=1 width=170><INPUT type=TEXT size=20 maxlength=50 name="Email" value="" ></td> <td colspan=16 height=22></td> </tr> <tr valign="top"> <td colspan=46 height=15></td> </tr> <tr valign="top"> <td colspan=20 height=3></td> <td align="right" colspan=21 rowspan=3 width=433><b><font color="#000099" face="Helvetica"><span style="font-size:14">Do not include email address in public list of those attending</span></font></b></td> <td colspan=5 height=3></td> </tr> <tr valign="top"> <td colspan=16 height=15></td> <td colspan=3 rowspan=1 width=15><INPUT type="checkbox" name="Do not include email address" value="true" ></td> <td colspan=1 height=15></td> <td colspan=5 height=15></td> </tr> <tr valign="top"> <td colspan=20 height=8></td> <td colspan=5 height=8></td> </tr> <tr valign="top"> <td colspan=46 height=25></td> </tr> <tr valign="top"> <td colspan=8 height=46></td> <td align="center" colspan=31 rowspan=1 width=514><b><font color="#000099" face="Helvetica" size="+1"><span style="font-size:18">Your Interest is because you are:<br>(</span></font></b><b><font color="#000099" face="Helvetica" size="-1"><span style="font-size:12">Please select all that applies)</span></font></b></td> <td colspan=7 height=46></td> </tr> <tr valign="top"> <td colspan=46 height=1></td> </tr> <tr valign="top"> <td colspan=4 height=3></td> <td colspan=1 rowspan=2 width=15><INPUT type="checkbox" name="Voices Member" value="true" ></td> <td colspan=26 height=3></td> <td colspan=1 rowspan=2 width=15><INPUT type="checkbox" name="Assisted Living Owner/Operator" value="true" ></td> <td colspan=14 height=3></td> </tr> <tr valign="top"> <td colspan=4 height=12></td> <td colspan=1 height=12></td> <td colspan=22 rowspan=2 width=267><b><font color="#000099" face="Helvetica"><span style="font-size:14">Member of Voices for Quality Care</span></font></b></td> <td colspan=3 height=12></td> <td colspan=1 height=12></td> <td colspan=10 rowspan=2 width=267><b><font color="#000099" face="Helvetica"><span style="font-size:14">Assisted LIving Owner/Operator</span></font></b></td> <td colspan=3 height=12></td> </tr> <tr valign="top"> <td colspan=6 height=7></td> <td colspan=5 height=7></td> <td colspan=3 height=7></td> </tr> <tr valign="top"> <td colspan=46 height=5></td> </tr> <tr valign="top"> <td colspan=4 height=3></td> <td colspan=1 rowspan=2 width=15><INPUT type="checkbox" name="Advocate" value="true" ></td> <td colspan=26 height=3></td> <td colspan=1 rowspan=2 width=15><INPUT type="checkbox" name="Ombudsman" value="true" ></td> <td colspan=14 height=3></td> </tr> <tr valign="top"> <td colspan=4 height=12></td> <td colspan=1 height=12></td> <td colspan=22 rowspan=2 width=267><b><font color="#000099" face="Helvetica"><span style="font-size:14">Advocate</span></font></b></td> <td colspan=3 height=12></td> <td colspan=1 height=12></td> <td colspan=10 rowspan=2 width=267><b><font color="#000099" face="Helvetica"><span style="font-size:14">Ombudsman</span></font></b></td> <td colspan=3 height=12></td> </tr> <tr valign="top"> <td colspan=6 height=7></td> <td colspan=5 height=7></td> <td colspan=3 height=7></td> </tr> <tr valign="top"> <td colspan=46 height=5></td> </tr> <tr valign="top"> <td colspan=4 height=3></td> <td colspan=1 rowspan=2 width=15><INPUT type="checkbox" name="Resident" value="true" ></td> <td colspan=26 height=3></td> <td colspan=1 rowspan=2 width=15><INPUT type="checkbox" name="Surveyor" value="true" ></td> <td colspan=14 height=3></td> </tr> <tr valign="top"> <td colspan=4 height=12></td> <td colspan=1 height=12></td> <td colspan=22 rowspan=2 width=267><b><font color="#000099" face="Helvetica"><span style="font-size:14">Resident</span></font></b></td> <td colspan=3 height=12></td> <td colspan=1 height=12></td> <td colspan=10 rowspan=2 width=267><b><font color="#000099" face="Helvetica"><span style="font-size:14">Surveyor</span></font></b></td> <td colspan=3 height=12></td> </tr> <tr valign="top"> <td colspan=6 height=7></td> <td colspan=5 height=7></td> <td colspan=3 height=7></td> </tr> <tr valign="top"> <td colspan=46 height=5></td> </tr> <tr valign="top"> <td colspan=4 height=3></td> <td colspan=1 rowspan=2 width=15><INPUT type="checkbox" name="Family or Friend of Resident" value="true" ></td> <td colspan=26 height=3></td> <td colspan=1 rowspan=2 width=15><INPUT type="checkbox" name="Legislator" value="true" ></td> <td colspan=14 height=3></td> </tr> <tr valign="top"> <td colspan=4 height=12></td> <td colspan=1 height=12></td> <td colspan=22 rowspan=2 width=267><b><font color="#000099" face="Helvetica"><span style="font-size:14">Family or Friend of Resident</span></font></b></td> <td colspan=3 height=12></td> <td colspan=1 height=12></td> <td colspan=10 rowspan=2 width=267><b><font color="#000099" face="Helvetica"><span style="font-size:14">Legislator</span></font></b></td> <td colspan=3 height=12></td> </tr> <tr valign="top"> <td colspan=6 height=7></td> <td colspan=5 height=7></td> <td colspan=3 height=7></td> </tr> <tr valign="top"> <td colspan=46 height=5></td> </tr> <tr valign="top"> <td colspan=4 height=3></td> <td colspan=1 rowspan=2 width=15><INPUT type="checkbox" name="Family Council Member" value="true" ></td> <td colspan=26 height=3></td> <td colspan=1 rowspan=2 width=15><INPUT type="checkbox" name="Local AAA" value="true" ></td> <td colspan=14 height=3></td> </tr> <tr valign="top"> <td colspan=4 height=12></td> <td colspan=1 height=12></td> <td colspan=22 rowspan=2 width=267><b><font color="#000099" face="Helvetica"><span style="font-size:14">Family Council Member</span></font></b></td> <td colspan=3 height=12></td> <td colspan=1 height=12></td> <td colspan=10 rowspan=2 width=267><b><font color="#000099" face="Helvetica"><span style="font-size:14">Local AAA</span></font></b></td> <td colspan=3 height=12></td> </tr> <tr valign="top"> <td colspan=6 height=7></td> <td colspan=5 height=7></td> <td colspan=3 height=7></td> </tr> <tr valign="top"> <td colspan=46 height=5></td> </tr> <tr valign="top"> <td colspan=4 height=3></td> <td colspan=1 rowspan=2 width=15><INPUT type="checkbox" name="Nursing Home Administrator" value="true" ></td> <td colspan=26 height=3></td> <td colspan=1 rowspan=2 width=15><INPUT type="checkbox" name="State Agency" value="true" ></td> <td colspan=14 height=3></td> </tr> <tr valign="top"> <td colspan=4 height=12></td> <td colspan=1 height=12></td> <td colspan=22 rowspan=2 width=267><b><font color="#000099" face="Helvetica"><span style="font-size:14">Nursing Home Administrator</span></font></b></td> <td colspan=3 height=12></td> <td colspan=1 height=12></td> <td colspan=10 rowspan=2 width=267><b><font color="#000099" face="Helvetica"><span style="font-size:14">State Agency</span></font></b></td> <td colspan=3 height=12></td> </tr> <tr valign="top"> <td colspan=6 height=7></td> <td colspan=5 height=7></td> <td colspan=3 height=7></td> </tr> <tr valign="top"> <td colspan=46 height=5></td> </tr> <tr valign="top"> <td colspan=4 height=3></td> <td colspan=1 rowspan=2 width=15><INPUT type="checkbox" name="Director of Nursing" value="true" ></td> <td colspan=26 height=3></td> <td colspan=1 rowspan=2 width=15><INPUT type="checkbox" name="Association Staff" value="true" ></td> <td colspan=14 height=3></td> </tr> <tr valign="top"> <td colspan=4 height=12></td> <td colspan=1 height=12></td> <td colspan=22 rowspan=2 width=267><b><font color="#000099" face="Helvetica"><span style="font-size:14">Director of Nursing</span></font></b></td> <td colspan=3 height=12></td> <td colspan=1 height=12></td> <td colspan=10 rowspan=2 width=267><b><font color="#000099" face="Helvetica"><span style="font-size:14">Association Staff</span></font></b></td> <td colspan=3 height=12></td> </tr> <tr valign="top"> <td colspan=6 height=7></td> <td colspan=5 height=7></td> <td colspan=3 height=7></td> </tr> <tr valign="top"> <td colspan=46 height=5></td> </tr> <tr valign="top"> <td colspan=4 height=3></td> <td colspan=1 rowspan=2 width=15><INPUT type="checkbox" name="Social Worker" value="true" ></td> <td colspan=26 height=3></td> <td colspan=1 rowspan=2 width=15><INPUT type="checkbox" name="Concerned Citizen" value="true" ></td> <td colspan=14 height=3></td> </tr> <tr valign="top"> <td colspan=4 height=12></td> <td colspan=1 height=12></td> <td colspan=22 rowspan=2 width=267><b><font color="#000099" face="Helvetica"><span style="font-size:14">Social Worker</span></font></b></td> <td colspan=3 height=12></td> <td colspan=1 height=12></td> <td colspan=10 rowspan=2 width=267><b><font color="#000099" face="Helvetica"><span style="font-size:14">Concerned Citizen</span></font></b></td> <td colspan=3 height=12></td> </tr> <tr valign="top"> <td colspan=6 height=7></td> <td colspan=5 height=7></td> <td colspan=3 height=7></td> </tr> <tr valign="top"> <td colspan=46 height=5></td> </tr> <tr valign="top"> <td colspan=4 height=3></td> <td colspan=1 rowspan=2 width=15><INPUT type="checkbox" name="Nursing Home Owner/Operator" value="true" ></td> <td colspan=26 height=3></td> <td colspan=1 rowspan=2 width=15><INPUT type="checkbox" name="Other" value="true" ></td> <td colspan=14 height=3></td> </tr> <tr valign="top"> <td colspan=4 height=12></td> <td colspan=1 height=12></td> <td colspan=22 rowspan=2 width=267><b><font color="#000099" face="Helvetica"><span style="font-size:14">Nursing Home Owner/Operator</span></font></b></td> <td colspan=3 height=12></td> <td colspan=1 height=12></td> <td colspan=10 rowspan=2 width=267><b><font color="#000099" face="Helvetica"><span style="font-size:14">Other - please specify in comments</span></font></b></td> <td colspan=3 height=12></td> </tr> <tr valign="top"> <td colspan=6 height=7></td> <td colspan=5 height=7></td> <td colspan=3 height=7></td> </tr> <tr valign="top"> <td colspan=46 height=29></td> </tr> <tr valign="top"> <td colspan=17 height=80></td> <td align="center" colspan=18 rowspan=1 width=342><b><font color="#000099" face="Helvetica" size="+1"><span style="font-size:18">Comments or Questions</span></font></b><b><font color="#000099" face="Helvetica"><span style="font-size:14"><br>If you have any special needs, please tell us of them here. If you checked the Other box, please explain here.</span></font></b></td> <td colspan=11 height=80></td> </tr> <tr valign="top"> <td colspan=46 height=19></td> </tr> <tr valign="top"> <td colspan=10 height=184></td> <td colspan=27 rowspan=1 width=490><TEXTAREA wrap=PHYSICAL rows=10 cols=58 name="Comments" > </TEXTAREA></td> <td colspan=9 height=184></td> </tr> <tr valign="top"> <td colspan=46 height=21></td> </tr> <tr valign="top"> <td colspan=11 height=152></td> <td align="center" colspan=25 rowspan=1 width=397><b><font face="Helvetica"><span style="font-size:14">Payment in advance is required. You may mail us a check to:<br>Voices for Quality Care (LTC), Inc.<br>P.O. Box 2251<br>Leonardtown, MD 20650<br><br>Or you may use a credit card by clicking on the "Make a Donation" button below.</span></font></b></td> <td colspan=10 height=152></td> </tr> <tr valign="top"> <td colspan=46 height=7></td> </tr> <tr valign="top"> <td colspan=22 height=3></td> <td colspan=1 rowspan=2 width=15><INPUT type="checkbox" name="I'll send you a check." value="true" ></td> <td colspan=23 height=3></td> </tr> <tr valign="top"> <td colspan=22 height=12></td> <td colspan=1 height=12></td> <td colspan=11 rowspan=2 width=267><b><font color="#000099" face="Helvetica"><span style="font-size:14">I'll mail you a check.</span></font></b></td> <td colspan=11 height=12></td> </tr> <tr valign="top"> <td colspan=24 height=7></td> <td colspan=11 height=7></td> </tr> <tr valign="top"> <td colspan=46 height=5></td> </tr> <tr valign="top"> <td colspan=22 height=3></td> <td colspan=1 rowspan=2 width=15><INPUT type="checkbox" name="I'll use the credit card donations link" value="true" ></td> <td colspan=23 height=3></td> </tr> <tr valign="top"> <td colspan=22 height=12></td> <td colspan=1 height=12></td> <td colspan=11 rowspan=2 width=267><b><font color="#000099" face="Helvetica"><span style="font-size:14">I'll use the credit card donations link.</span></font></b></td> <td colspan=11 height=12></td> </tr> <tr valign="top"> <td colspan=24 height=7></td> <td colspan=11 height=7></td> </tr> <tr valign="top"> <td colspan=46 height=21></td> </tr> <tr valign="top"> <td colspan=27 height=33></td> <td colspan=7 rowspan=1 width=83><INPUT type="submit" name="Submit1" value="Submit" ></td> </form> <td colspan=12 height=33></td> </tr> </table> </body> </html>  </div> <bR> <bR> <DIV ALIGN="LEFT"></DIV> <div> To Pay On Line click the button below.</div> <bR> <div>  <form action="https://www.paypal.com/cgi-bin/webscr" method="post"> <input type="hidden" name="cmd" value="_s-xclick"> <input type="image" src="https://www.paypal.com/en_US/i/btn/x-click-but21.gif" border="0" name="submit" alt="Make payments with PayPal - it's fast, free and secure!"> <img alt="" border="0" src="https://www.paypal.com/en_US/i/scr/pixel.gif" width="1" height="1"> <input type="hidden" name="encrypted" value="-----BEGIN PKCS7-----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-----END PKCS7----- "> </form>  </div> <bR> <div> <A HREF="id74.htm" TARGET="_top" TITLE="Directions to Waldorf"><U><B>For directions to the Waldorf Jaycees, click HERE.</B></U></A></div> </td> </tr></table></body>