PREP LTC Enrollment Form – Year 6 – 2026-2027

Please complete the following Enrollment Agreement Form to participate in Year 6 of the Preceptor Resource and Education Program in Long-Term Care (PREP LTC). The deadline to enroll in Year 6 of the program is January 30th, 2027.

Please note LTC homes are eligible to receive up to $50,000. Please see below for additional details and new reporting requirements.

Select your LTC Home(Required)

If you are unable to select your LTC home from the list, please DO NOT select another LTC home. Instead, please contact us before continuing at prepltc@the-ria.ca.

Home Name

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PREP Allotment

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Address

Address Line 2

City

Province

Postcode

Section 1: Program Contact Information

Please provide the requested contact information below. At minimum, homes are required to name a Primary Contact, Secondary Contact, and Finance Individual for PREP LTC team members to connect with throughout the program year.

Primary Contact Information(Required)

First Last

Job Title(Required)

Email(Required)

Phone(Required)

Phone Ext.

Briefly describe this individual's role with respect to planning and/or managing student placements and the PREP LTC program within your home.(Required)

Secondary / Alternate Contact Information(Required)

First Last

Job Title(Required)

Email(Required)

Phone(Required)

Phone Ext.

Briefly describe this individual's role with respect to planning and/or managing student placements and the PREP LTC program within your home.(Required)

Please select one of the following options(Required)

Our Student Coordinator is the Primary Contact listed above

Our Student Coordinator is the Secondary / Alternate Contact listed above

Our Student Coordinator is someone else

We do not have a Student Coordinator in our LTC home

Student Coordinator Contact Information(Required)

First Last

Job Title(Required)

Email(Required)

Phone(Required)

Phone Ext.

Briefly describe this individual's role with respect to planning and/or managing student placements and the PREP LTC program within your home.(Required)

Please select one of the following options(Required)

Our Finance Individual is the Primary Contact listed above

Our Finance Individual is the Secondary / Alternate Contact listed above

Our Finance Individual is someone else

Finance Individual Contact Information(Required)

First Last

Job Title(Required)

Email(Required)

Phone(Required)

Phone Ext.

Please select one of the following options(Required)

Our Corporate Contact is the Primary Contact listed above

Our Corporate Contact is the Secondary / Alternate Contact listed above

Our Corporate Contact is someone else

We do not have a Corporate Contact in our LTC home

Corporate Contact Information(Required)

First Last

Job Title(Required)

Email(Required)

Phone(Required)

Phone Ext.

Section 2: Student Placement Program Information

Please respond to the following questions related to your home’s student placement program. Your responses will help the PREP LTC team understand your home’s unique situation.

How many clinical placements in total is your LTC home planning to host between April 1st, 2026 and March 31st, 2027?

PSW:(Required)