Neonatal Touch & Massage Certification Hosting Information Details

Name of Person Hosting NTMC

Phone Number of Hosting Person*

Email Address of Hosting Person*

Date of NTMC Hands-On Training:

Please note if COVID or another event/situation prevents Live contact at the NTMC Hosting Facility, NTMC will continue in a Virtual Format on the same dates.

Hospital Name:*

Hospital Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Hospital NICU or Rehab Phone

List names and addresses below of sister hospitals/hospitals within hospital system that have been agreed to between CTC and your hospital representative to be part of the 20% hosting discount:

Ship to Name for Training Materials - "Attention"*

First Last

Ship to Address for Training Materials*

Street Address Address Line 2 City State ZIP Code

Name of Person Signing Agreement (please include credentials, i.e. BSN, OTR/L*

Title of Person Signing Agreement (i.e., DIrector of ?, NICU Nurse Manager, Rehab Manager)*

Email of Person Signing Agreement*

Email to Send Contract*

Name of Building, GPS (MapQuest) Address and Rooms where NTMC will occur (room must be large enough for 40 participants in classroom style sitting and large separate or surrounding area for lab with 12 tables- approx 1,200 square feet). Please provide room dimensions and send a picture if able.*

By entering initials below, the hosting site agrees to provide 15 pillows with pillow cases and 40 baby blankets

Closest Airport(s) to the Hospital (including approximate distance and travel timeframe)*

Directions to Hospital (specific directions when approaching hospital or specifics to find the rooms)*

Hospital Parking Information (i.e., valet, parking garage available and where, cost)*

Proximity of Cafeteria to Venue Location (or local restaurants that deliver to venue - only 45 minutes for lunch)*

Anticipated number of staff (minimum of 15 OT, PT, SLP or RN) from your facility that will attend NTMC (General number of slots for the course to hold for your staff)*

List area hospitals with NICUs within a 3 hour radius*

Please List Three Hotels close to NTMC Hands-On Training Location

1. Hotel Name*

Hotel Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Hotel Phone*

Hotel Website*

Approximate Price at time of year of NTMC (if known or if arrangements for special pricing exists)*

Distance from NTMC Hand-On Training Location*

2. Hotel Name*

Hotel Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Hotel Phone*

Hotel Website*

Approximate Price (if known or if arrangements for special pricing exists)*

Distance from NTMC Hands-On Training Location*

3. Hotel Name*

Hotel Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Hotel Phone*

Hotel Website*

Approximate Price (if known or if arrangements for special pricing exists)*

Distance from NTMC Hands-On Training Location*

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