Workers' Compensation Conference - 19th Annual - June 1-2, 2020
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19th Annual
Workers’ Compensation
Conference
June 1-2, 2020
Hershey Lodge & Convention Center
Hershey, Pennsylvania
Tom Wolf | Governor
Conference Information
Fee Credit Information
Conference registration is $250 per person and The Pennsylvania Bar Institute is providing
includes admission to conference workshops, continuing legal education credits. Also, various
exhibits, lunches, morning/afternoon breaks (on continuing education credits are available from
June 1-2), and dinner on June 1. To register, the PA Association of Rehabilitation Professionals
see page 2. and Preferred Systems Inc. Please contact these
credit organizations directly for credit information
Cancellation Policy and cost. These costs are in addition to the
Cancellations and refund requests must be conference registration fee. To register for
received by the bureau no later than May 22, credits, please visit the credit websites:
2020. No refunds will be made after this date
due to the bureau’s financial commitment to PBI: www.pbi.org
the convention facility for food, beverages, PARP: www.rehabpro.org
meeting rooms and services. There will be no Preferred Systems Inc.: www.preferrededucation.com
exceptions to this refund policy.
This activity has been submitted to AAOHN for
Walk-In Registration approval to award contact hours. AAOHN is
Walk-in registrations will not be accepted accredited as an approver of continuing nursing
without contemporaneous payment. education by the American Nurses Credentialing
Center’s Commission on Accreditation.
Lodging/Reservations The continuing nursing education credits for
Reservations for overnight accommodations at this activity are sponsored by the Pennsylvania
the Hershey Lodge must be made by contacting Association of Occupational Health Nurses
the lodge on or before May 1, 2020, at (PAAOHN). Participants may receive partial credit
855-729-3108 or visit: (from 1.25 to 8.75 contact hours) depending on
https://book.passkey.com/go/BWCC2020 the number of sessions attended. The cost for
CNE credits is free for PAAOHN members and
When making your reservations, advise the $40 for non-members. If you have any questions,
lodge that you are attending the “Bureau of please feel free to contact
Workers’ Compensation Conference June Ann Marie Loiseau, DNP, RN, CSN, CCM at
1-2, 2020” to get the conference room rate of annmarie.loiseau@desales.edu, or
$205, plus 11 percent tax per room, per night. Donna Sponaugle, BS/ED, RN, COHN-S, at
If you are attending and exhibiting, make the 717-299-1265 or dsponaugle@hersheys.com.
lodge aware of that as well.
Hershey Lodge & Convention Center
West Chocolate Avenue & University Drive
Hershey, PA 17033
717-533-3311
1
General Attendee Registration
General Attendee Registration
Questions/Special Accommodations
Questions/Special Accommodations Check your
your affiliation:
affiliation:
IfIf you
you require
requirean
anaccommodation
accommodationdue dueto to
a a
disability, have Case management
Case management
disability, haveaaspecial
specialdietary
dietaryneed
needrequest or
request
have
or anyany
have questions, call call
questions, the bureau’s helpline:
the bureau’s Claimantattorney
Claimant attorney
helpline:
• Toll free inside PA: 800-482-2383 Court reporting
Court reporting
•• Local
Toll free
andinside PA:
outside PA:800-482-2383
717-772-4447
Defense attorney
Defense attorney
•• People
Local and withoutside
hearing PA:
loss717-772-4447
only:
toll free with
• People inside PA: TTY
hearing 800-362-4228
loss only: Employer
Employer
local
tolland
freeoutside
inside PA:
PA: TTY
TTY717-772-4991
800-362-4228 Government
Government
localra-li-bwc-helpline@pa.gov
email: and outside PA: TTY 717-772-4991
email: ra-li-bwc-helpline@pa.gov Health &&Safety
Health Safety
To Register Online: Health care
Health careindustry
industry
To Register
Register Online:
online at: www.dli.pa.gov, click on
Register online
Businesses, nextat: www.dli.pa.gov,
click click on
on Workers’ Compensation Insuranceindustry
Insurance industry
Businesses,
Services, andnext
thenclick on Workers’Seminars,
on Conferences, Investigator
Investigator
Compensation
Training. Services and then on
Conferences, Seminars, Training. Labor
Labor
To Register by Mail: Medical products
products
To Register By Mail: Medical
Mail your check or money order for $250, payable
Mail
to theyour check or money
of PA,order $250,
for completed Nurse
Commonwealth and this Third-party administrator
payable to the
form by May 22,Commonwealth
2020, to: of PA, and
this completed form by May 24, 2019, to: Third-party administrator
Translation
BureauofofWorkers’
Bureau Workers’ Compensation
Compensation Translation
Transportation
Attn: Conference
Attn: Conference Transportation
Utilization review
1171S.
1171 S.Cameron
CameronSt.,St.,Room
Room324
324
Harrisburg,PA
Harrisburg, PA17104-2501
17104-2501 Utilization rehabilitation
Vocational review
Provide all information
informationrequested
requestedbelow
below Vocational
Other rehabilitation
(specify):
Provide all (or(or
attach
attach a business
a business card). Incomplete
card). Incomplete forms willforms
not bewill Other (specify):
not be accepted.
accepted. One registration
One registration per form;per form;
please make
please make
copies as copies as needed.
needed.
Name:
Company:
Address:
City:
State, ZIP:
County:
Phone:
Fax:
Email:
I Iwill
willattend
attenddinner
dinneron
onJune
June3:1: YES
YES NONO
First-timeattendee:
First-time attendee: YES
YES NONO
2
Exhibitor Registration
Exhibits Exhibit Schedule
Exhibit registration is $750 per booth. • Sunday, May 31, 5 p.m.–9 p.m.
On-site registration in the Great American
Fee Includes: Lobby outside Exhibit Hall (Red, White & Blue
• Conference registration for two people rooms) and setup in the Exhibit Hall.
• Meals and breaks as indicated on the
• Tuesday, June 2, 1 p.m.
conference agenda
Door prize announcements (Names of
• One 8x10 foot exhibit space
prize winners will be displayed in the Great
• One 110v electrical outlet
American Lobby.)
• One 6-foot table, draped
• Draped side rails and backdrop • Tuesday, June 2, 2 p.m.–5 p.m.
• One name sign (7 inches x 44 inches), Tear down (Exhibitors who tear down before 2
includes booth # and company name p.m. will be placed at the bottom of the list for
• Two chairs exhibiting at the next Workers’ Compensation
• One trash can Conference.)
• Wall-to-wall carpeting
• Limited security during lunch breaks
• on June 1-2 (room will be locked
during lunch breaks)
• 24-hour roaming security
To Register:
Register online at: www.dli.pa.gov, click
on Businesses, next click on Workers’
Compensation Services, and then on
Conferences, Seminars, Training.
All exhibitors are required to register online and
pay the fee of $750 with a credit card by May
22, 2020.
Booths are assigned on a first-come, first-
served basis, so please submit your registration
as early as possible. No booth will be reserved
without submission of the registration, the fee,
the exhibitor’s Certificate of Liability and a
Requirements Acknowledgement form signed
by the two exhibit booth representatives
(acknowledgement form is available at:
www.dli.pa.gov, click on Businesses, next
click on Workers’ Compensation Services and
then on Conferences, Seminars, Training or
by emailing: ra-li-bwc-helpline@pa.gov).
Upon receipt of payment and documentation, a
confirmation letter will be forwarded. A separate
notice with floor plan and booth assignment will
follow.
3
Agenda
Day 1 / Monday, June 1, 2020 Learn about the IRE process from the time an IRE
can be requested, through the receipt of the IRE
determination, and how the IRE determination
7 a.m. Registration (Chocolate Lobby)
impacts liability for a claim.
Continental Breakfast (Exhibit Hall)
8:30 a.m. Welcome/Opening Remarks: Jerry 10:30 a.m. – 11 a.m. Break/Exhibits
Oleksiak, Secretary, PA Dept. of Labor & (Exhibit Hall)
Industry (Chocolate Ballroom)
11 a.m. – 12:15 p.m. Breakout Sessions
9:15 a.m. – 10:30 a.m. Breakout Sessions
Basic WC Law – Part 2
Basic WC Law – Part 1 Basic
Basic Moderated by: Elizabeth A. Crum, WC Office of
David B. Torrey, WCJ, WC Office of Adjudication (retired), Harrisburg
Adjudication, Pittsburgh Stephen S. Bloomburg, Esq., Post & Schell PC,
Pittsburgh
Previously offered as WC 101, Workers’
Nariman P. Dastur, Esq., DeAngelis, Dastur &
Compensation Judge David Torrey provides
Associates PC, Pittsburgh
a basic overview of workers’ compensation Marie Ehling, School Districts Insurance
in Pennsylvania, including a discussion on its Consortium, North Wales
history, basic entitlements, wage loss, course
of employment and disability/partial disability. This detailed discussion will follow the flow of
the claim process from the moment of injury until
Legislative Process the final adjudication. Speakers will address
Intermediate frequently asked questions about the workers’
Moderated by: Adrienne Breslin, compensation law and will give basic information
Lackawanna Insurance Group, Wilkes-Barre about what the law is and what it does.
Jonathan C. Greer, Insurance Federation of PA
Legal Updates
Inc., Harrisburg
[Repeated Tuesday at 1:00 p.m.]
Thomas Previc, Pennsylvania Association for
Justice, Harrisburg Intermediate
Moderated by: Barbara L. Hollenbach, Esq.,
Hear from experienced and respected “Hands Norris, McLaughlin & Marcus, Allentown
on the Hill” who will provide a brief overview Barbara E. Holmes, Esq., Blaufeld, Schiller &
of the legislative process and discuss pending Holmes LLP, Pittsburgh
or recently enacted workers’ compensation Terry W. Knox, WCJ, WC Office of Adjudication,
legislation. Reading
Peter J. Weber, Esq., Weber Gallagher,
Wearable Technology in the Workplace Philadelphia
Intermediate/Advanced
An annual favorite, join in this discussion of the
Zach Craft, One Call Medical, Jacksonville, FL
leading cases and current, potentially problematic
Learn how new technology may not only reduce issues facing workers’ compensation practitioners.
work injuries, but also help to reduce financial,
operational and legal challenges associated Adjusterology
with workplace injuries, building a healthier Basic
workforce and a safer workplace. Moderated by: Susan M. Emmet, Eastern
Alliance Insurance Company, Lancaster
Healthcare Services Review Division Update Stephen P. Dalansky, Metz Culinary
Basic/Intermediate Management, Dallas
Moderated by: Marianne H. Saylor, Director, Gregory J. Fischer, Esq., Carpenter, McCadden &
Bureau of Workers’ Compensation, Harrisburg Lane LLP, Wexford
Patricia Clemens, Bureau of Workers’ Steve Reich, Eastern Alliance Insurance
Compensation, Harrisburg Company, Lancaster
Karla Henneman, Bureau of Workers’
Compensation, Harrisburg
4Discuss and learn best practices from claim Employers Unplugged
inception to ensure effective management of the Basic
claim and achieve most favorable outcomes. Moderated by: Gregory J. Fischer, Esq.,
Carpenter, McCadden & Lane LLP, Wexford
WCAIS-New Tips and Tricks Joseph C. Rietmulder, TE Connectivity,
Intermediate Middletown
Moderated by: Susan B. Caravaggio, WCJ, Jane LaGreca, Safety & Risk Specialists,
Office of Adjudication, Williamsport Doylestown
Stevi Leech, WC Office of Adjudication, Anthony Lauro, Vanalt Electrical Construction,
Johnstown Inc., Yeadon
Harte Pricer, Bureau of Workers’ Compensation,
These experienced large, medium, and small
Harrisburg
employers will address evolving challenges and
Learn tips and tricks on how to effectively and topics such as workforce education, pre-injury
productively utilize the WCAIS system. training, post-injury medical care and the claims
management process. The panel will discuss
12:15 p.m. – 1:45 p.m. Lunch (Chocolate coordination between the adjuster, employer,
Ballroom) medical providers and counsel to support a
successful modified duty and return to work
1:45 p.m. – 3 p.m. Breakout Sessions
program.
Managing Pain through Alternatives to
Gig Economy
Opioids (not Medical Marijuana)
Intermediate/Advanced
Basic/Intermediate
Moderated by: David B. Torrey, WCJ, WC Office
Moderated by: Donna K. Sponaugle, Y&S
of Adjudication, Pittsburgh
Candies, Lancaster
Joseph C. Huttemann, Esq., Martin Law,
Kenji Saito, MD/JD, MaineGeneral Health,
Philadelphia
Augusta, ME
Bradley Smith, Esq., Galfand Berger LLP,
Alternative pain management will be identified to Philadelphia
assist patients with effective pain control while Justin D. Beck, Esq., Thomas, Thomas, and
empowering them in their own treatment plan. Hafer, Pittsburgh
An update to the 2018 presentation due to the
As the Claim Turns – Part 1
fast-paced changes in this area of the law. The
Basic panel will provide a briefing on the trend towards
Moderated by: Daniel Snyder, Esq, WCJ, WC workers laboring in the gig economy with a focus
Office of Adjudication, Allentown on employment status, safety, and insurance
Deborah J. Schwartz, Esq., Bureau of Workers’ implications.
Compensation, Office of Chief Counsel,
Harrisburg 3 p.m. – 3:30 p.m. Break/Exhibits (Exhibit Hall)
Jason Woodruff, Lackawanna Insurance Group, 3:30 p.m. – 4:45 p.m. Breakout Sessions
Wilkes-Barre
Aimee Hernandez, Chic-Fil-A, Pittsburgh Workers’ Compensation Game Show
John J. Beichert, Esq., Haggerty, Goldberg,
Intermediate
Schleifer & Kupersmith, Reading
Edward R. Carpenter Jr., Esq., Carpenter,
Heather Zambelli, Esq., Cipriani & Warner,
McCadden & Lane LLP, Media
Pittsburgh
Christopher A. DiMeo, Esq., Carpenter,
This year’s session will focus on a WC claim McCadden & Lane LLP, Media
from start to finish. We will focus on issues Marla A. Joseph, Esq., Law Offices of Marla A.
regarding employment in the 21st century Joseph LLC, Jenkintown
workforce, including issues with the gig John W. McTiernan, WCJ, WC Office of
economy and contingent workforce. Adjudication, Philadelphia
Test your workers’ compensation knowledge. This
fun & informative session takes the attendees
through the nuances of WC in PA.
5As the Claim Turns–Part 2
Basic
Day 2 / Tuesday, June 2, 2020
Moderated by: Daniel Snyder, WCJ, WC Office 7:30 a.m. Continental Breakfast (Exhibit Hall)
of Adjudication, Allentown
Deborah J. Schwartz, Esq., Bureau of Workers’ 8 a.m. – 8:30 a.m. Kids’ Chance Presentation
Compensation, Office of Chief Counsel, (Wild Rose)
Harrisburg
Jason Woodruff, Lackawanna Insurance Group, Kids’ Chance of Pennsylvania…We are all
Wilkes-Barre about the Kids!
Aimee Hernandez, Chic-Fil-A, Pittsburgh Elizabeth A. Crum, President, Kids’ Chance of PA
John J. Beichert, Esq., Haggerty, Goldberg,
The mission of Kids’ Chance of Pennsylvania Inc.
Schleifer & Kupersmith, Reading
(Kids’ Chance of PA) is to provide scholarship
Heather Zambelli, Esq., Cipriani & Warner,
grants for college and vocational education to
Pittsburgh
children of Pennsylvania workers who have
been killed or seriously injured in a work-related
Continuation of Part 1.
accident resulting in financial need. For the
2019-2020 school year, Kids’ Chance has granted
A Physician Speaks: Treatment & Evaluation
$179,000 in scholarships to 57 deserving college
of the Injured Worker
students. Join Elizabeth Crum, Kids’ Chance
Intermediate President, to learn more about the organization
Co-Moderated by: Adrienne Breslin, and how you can help us spread our mission to
Lackawanna Insurance Group, Wilkes-Barre, reach more students in need of our scholarship.
and Joseph C. Huttemann, Esq., Martin Law,
Philadelphia 8:30 a.m. – 9:45 a.m. Breakout Sessions
Robert W. Mauthe, MD, Office of Robert
Mauthe, MD, PC, Center Valley Active Shooter
Basic
Hear from a well-respected physician who treats
Lt. Kerby L. Young, PA State Police, Harrisburg
injured workers and provides IME’s on behalf of
injured workers and insurance companies. Valuable information for all attendees concerning
steps necessary to protect yourself and
UEGF/Compliance Updates others during an active shooter situation. This
Basic presentation from the PA State Police is cutting
Moderated by: Joseph DeRita, Director, WC edge training, providing each attendee with the
Office of Adjudication, Harrisburg knowledge for saving lives during the chaotic
Kimberly D. Mazin, Esq., Bureau of Workers’ moments active shooters present.
Compensation, Office of Chief Counsel,
Harrisburg Role of the Nurse Practitioner & Physicians’
Jeffrey S. Gross, Esq., Gross & Kenny LLC, Assistant in Treatment of the Injured Worker
Philadelphia Advanced
Michael D. Schaff, Esq., Schaff & Young, PC, Moderated by: Donna K. Sponaugle, Y&S
Philadelphia Candies, Lancaster
Kim Olszewski, Mid-State Occupational Health
Review of practical considerations since Act 132
Services Inc., Lewisburg
George Chistakoff, Premise Health, Reading,
Wesley J. Rish, Esq., Rish Law Office, LLC,
Harrisburg
John W. McTiernan, WCJ, WC Office of
5 p.m. – 7 p.m. Dinner (Chocolate Ballroom)
Adjudication, Philadelphia
Identify the roles, responsibilities, and scope of
practice of these professions. Describe the
qualifications of NPs and PAs to diagnose and
6treat work-related injuries and illnesses, as well Lewis L. Wolfgang, Esq., Cipriani & Werner,
as work restrictions or modified duty. Discuss Pittsburgh
proposed bills in past and current sessions in Kelly Hemple, Esq., Krasno, Krasno & Onwudinjo
the PA legislature. Law, Pottstown
Harriet A. Gaither, CM Regent, Mechanicsburg
Employment Law Interaction with WC: A Steven Minnich, WCJ, WC Office of Adjudication,
Case Study Pittsburgh
Advanced Leslie Reyes, Mediquest Staffing & Homecare,
Robert J. Baker, Esq., The Chartwell Law Inc., Lancaster
Offices, Harrisburg You will get 50 tips in 50 minutes in this fast-paced
Sean A. Casey, Esq., Casey Legal, Pittsburgh presentation. Hear from leading participants in the
This session will address proper and effective WC system some of the most unique tips from their
administration of a workers’ compensation areas of expertise. There will be time for questions
claim in the context of issues raised by the at the end.
ADA, FMLA, COBRA, the Unemployment
Compensation Law and privacy issues. Medical Cost Regulations – Part 1
(Pre-Litigation)
Avoiding Litigation Intermediate
Intermediate Moderated by: Adrienne Breslin, Lackawanna
Moderated by: Linda G. Millas, J.P. Mascaro & Insurance Group, Wilkes-Barre
Sons, Audubon Patricia Clemens, Bureau of Workers’
Gregory J. Fischer, Esq., Carpenter, McCadden Compensation, Harrisburg
and Lane, LLP, Wexford David B. Torrey, WCJ, WC Office of Adjudication,
Michael Quatrini, Esq., Quatrini Rafferty Law, Pittsburgh
Pittsburgh Linda A. Lengle, Hoover Rehabilitation Services,
Laurie Heagy, East Penn Manufacturing/Deka Inc., Mechanicsburg
Batteries, Lyon Station Considerations and procedures following receipt
In this session, the panel will present of a medical bill; proper submission of bills
collaborative strategies and insights to facilitate and documentation; legal sufficiency, repricing
the WC claim process and avoid adversarial and downcoding, and regulatory and statutory
outcomes. provisions.
9:45 a.m. – 10:15 a.m. EDI Practices and Pitfalls
Break/Exhibits (Exhibit Hall)
Intermediate
10:15 a.m. – 11:30 a.m. Breakout Sessions Moderated by: David A. Cicola, WCJ, WC Office
of Adjudication, Johnstown
Workplace Security Hendrick I. Penn, IV, Esq., Weber Gallagher,
Basic Pittsburgh
Moderated by: Joseph DeRita, Director, WC Harte Pricer, Bureau of Workers’ Compensation,
Office of Adjudication, Harrisburg Harrisburg
Lt. Kerby L. Young, PA State Police, Harrisburg Learn to comply with EDI protocols and navigate
This session provides proactive informational the issues involved with EDI transactions to
steps on securing your workplace to minimize decode the EDI system and avoid potential
exposure to workplace violence situations. penalty situations.
Included will be diffusion techniques that can 11:30 a.m. – 1 p.m. Lunch (Chocolate
be utilized to deescalate potentially violent Ballroom)
behaviors and save lives.
1 p.m. – 2:15 p.m. Breakout Sessions
50 Tips in 50 Minutes
Intermediate/Advanced
Moderated by: Shawn Gooden, Esq., Weber
Gallagher, Harrisburg
7Legal Updates [Repeat] employer resources, and evidence-based
Intermediate practice. Participants will have an opportunity to
Moderated by: Barbara L. Hollenbach, Esq., practice mindfulness.
Norris, McLaughlin & Marcus, Allentown
Terry W. Knox, WCJ, WC Office of Adjudication,
Reading
Peter J. Weber, Esq., Weber Gallagher, 2:15 p.m. Conference Adjourns
Philadelphia
Judges Unplugged
Intermediate
Moderated by: Lawrence R. Chaban, Esq.,
AlpernSchubert PC, Pittsburgh
Elizabeth A. Crum, Retired WCJ, Hanover
Beverly Doneker, Retired WCJ, Shippensburg
Mary Kathleen Vallely, Retired WCJ, Pittsburgh
Karl K. Baldys, Retired WCJ, Williamsport
Come and hear unvarnished opinions and
candid discussion from some of the most
experienced, retired workers’ compensation
judges.
Medical Cost Regulations – Part 2 (Issues in
Litigation)
Advanced
Moderated by: Adrienne Breslin, Lackawanna
Insurance Group, Wilkes-Barre
David B. Torrey, WCJ, WC Office of
Adjudication, Pittsburgh
Patrick M. Donan, Esq., Steiner, Segal, Miller &
Donan, Philadelphia
Shawn Gooden, Esq., Weber Gallagher,
Harrisburg
Attend this session to gain an understanding of
the processes and current issues in fee review
appeals; the evidence required; the burden of
proof, evidentiary issues, practical tips, avoiding
common errors, and understanding the statute
and regulations.
Mental Health Issues
Intermediate
Moderated by: Ann Marie Loiseau, DeSales
University, Center Valley
Beth Smith, Fox Chase Cancer Center,
Philadelphia
Jonathan Grau, Work Solutions Lead National
Council for Behavioral Health, Washington DC
This session will cover the definition of
depression and the impact on health. The
session will also cover the impact of depression
in the workplace, potential employee and
8Tee Off for the Kids!
Tee Off for the Kids!
Celebrate the 15th Annual Kids’ Chance of Pennsylvania Golf Outing
Tee Off for the Kids!
Sunday, May 31, 2020 Golfer Registration Opens: 11:00am
Celebrate the 15th Annual Kids’ Chance of Pennsylvania Golf Outing
Hershey Country Club Recognition Luncheon: 12:00pm (For Partners/
1000 E. Derry Rd • Hershey, PA 17033 Scholars/Friends and Golfers)
Tee Off for the Kids!
Sunday, May 31, 2020 Golfer1:30pm
Tee-Off: Registration Opens: 11:00am
Celebrate
Hershey Country the
Club 15th Annual Kids’ Chance of Pennsylvania Golf Outing Cocktails/Dinner to follow Golf
Recognition Luncheon: 12:00pm (For Partners/
1000 E. Derry Rd • Hershey, PA 17033 Scholars/Friends and Golfers)
Sunday, May 31, 2020 Tee-Off:
Golfer 1:30pmOpens: 11:00am
Registration
Celebrate the
Hershey Country Club
15th Annual Kids’ Chance
Registration Formof Luncheon:
Pennsylvania
Cocktails/Dinner
Recognition to follow Golf(ForGolf
12:00pm Outing
Partners/
1000 E. Derry Rd • Hershey, PA 17033 Scholars/Friends
Deadline 5/15/2020 and Golfers)
Sunday, May 31, 2020 Golfer Registration Opens: 11:00am
Tee-Off: 1:30pm
Hershey Country Club Recognition Luncheon: 12:00pm (For Partners/
Golfers Registration Form to follow Golf
1000 E. Derry Rd • Hershey, PA 17033
Cocktails/Dinner
Scholars/Friends and Golfers)
1. Captain ____5/15/2020
Deadline Individual Golfer(s) @ $225 Each (Includes Lunch & Dinner)
Tee-Off: 1:30pm
____ Hole Sponsorship(s)
Cocktails/Dinner @ $250
to follow Each (Only one vendor sponsor per hole,
Golf
Golfers
2. Registration Form
NO splitting fee between vendors. Does not include lunch or dinner.)
____ Foursome and Hole Sponsorship Package(s) @ $1,100 Each
Deadline 5/15/2020
1.3.Captain ____ Individual
(Includes Golfer(s)
Four Golfers, @ $225Lunch
Hole Sponsor, Each
and(Includes
Dinner) Lunch & Dinner)
Registration
____
____ Form
Hole Sponsorship(s)
Luncheon(s) @ $40 Each@ $250 Each (Only one vendor sponsor per hole,
Golfers ____5/15/2020
Deadline Dinner(s) @ $50
NO splitting Each vendors. Does not include lunch or dinner.)
fee between
2.4.
1. Captain ____ Individual
____ Foursome Golfer(s) @ $225
and Hole Each (Includes
Sponsorship Lunch @
Package(s) & Dinner)
$1,100 Each
3.
Golfers ____ Hole Sponsorship(s)
(Includes Four Golfers,@ $250
Hole EachLunch
Sponsor, (Only and
one Dinner)
vendor sponsor per hole,
NO splitting fee between vendors. Does not include lunch or dinner.)
2. 1. Captain ____Individual
____ Luncheon(s) @ $40
Golfer(s) EachEach (Includes Lunch & Dinner)
@ $225
I will not be able to attend, but please accept my donation
____ of Dinner(s)
$______and
Foursome
____ in support
@ Hole
$50 of Kids’
Sponsorship
Each Chance of@
Package(s) PA.
$1,100 Each
____ Hole Sponsorship(s) @ $250 Each (Only one vendor sponsor per hole,
4. (Includes Four Golfers, Hole Sponsor, Lunch and Dinner)
3. 2. NO splitting fee between vendors. Does not include lunch or dinner.)
____
Kids’ Chance of Pennsylvania is a register, tax-exempt 501(c)(3) non-profit organization.
____AllLuncheon(s)
contributions
Foursomeare @tax $40
and Hole Each
deductible and contributors
Sponsorship will receive a letter
Package(s) of
@ $1,100 Each
____ Dinner(s) @ $50 Each
4.acknowledgement
3.
for tax purposes. (Includes Four Golfers, Hole Sponsor, Lunch and Dinner)
I will not be able to attend, but please accept my donation of $______
____ Luncheon(s) @ $40inEach support of Kids’ Chance of PA.
____ Dinner(s) @ $50 Each
4.
Thank you for your support. You may register online at http://www.kidschanceofpa.org and pay by credit card. Or fill
Kids’ Chance
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tax-exempt online
501(c)(3) at http://www.kidschanceofpa.org
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acknowledgement foryour check, payable to Kids’ Chance of Pennsylvania, Inc., 1231 Highland Ave., Fort Washington, PA 19034
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City: ST
Thank you for your support. You may register online at http://www.kidschanceofpa.org Zip Code _________
and pay by credit card. Or fill out this form and
Name: send your check, payable to Kids’ Chance of Pennsylvania, Inc., 1231 Highland Ave., Fort Washington, PA 19034
Phone:
Thank you for your support. You may registerEmail:
online at http://www.kidschanceofpa.org and pay by credit card. Or fill out this form and
Name:
Address: send your check, payable to Kids’ Chance of Pennsylvania, Inc., 1231 Highland Ave., Fort Washington, PA 19034
Name:
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My name is Malia, and I am a 2019-20 Kids’ Chance Scholarship Recipient. This is my first year receiving this scholarship and I am so
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with a cumulative GPA of 3.58. I made Dean’s List for both the fall and spring semesters as well. I am also
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Widener University School of Nursing Class of 2022Outing Sponsor Agreement
nual Kids’ Chance of PA Golf Outing
ion Name (as it will appear on event materials)
ame Title:
Golf Outing Sponsor Agreement
15th Annual Kids’ Chance of PA Golf Outing
State: Zip:
Golf Outing Sponsor Agreement
15th Annual Name
Organization Kids’ (as
Chance of PA Golf
it will appear Outing
on event materials)
) E-mail:
Contact Name
Organization Name (as it will appear on event materials) Title:
mptly Address:
submit your company’s website and your company's logo in high resolution JPEG or EPS format to
Contact Name Title:
ce of PA office at info@kidschanceofpa.org. Material received after May 15, 2020 will not appear on signa
ram. Address:
City: State: Zip:
Phone: (
City: ) E-mail: State: Zip:
ship Levels:
Please (promptly
Phone: ) submit your company’s websiteE-mail:
and your company's logo in high resolution JPEG or EPS format to the
Kids' Chance of PA office at info@kidschanceofpa.org. Material received after May 15, 2020 will not appear on signage or
Luncheon (2 @ $4,000)
in the program.
Please
Directory/Program Sponsor ($1,000)
promptly submit your company’s website and your company's logo in high resolution JPEG or EPS format to the
Dinner Sponsor
Kids' Chance of($3,000) Audio/Visual
PA office at info@kidschanceofpa.org. Material received Sponsor
after May 15, 2020 will not($750)
appear on signage or
in Sponsorship
Beverage Carts (2 Levels:
the program. @ $2,000) Gift Basket Sponsor ($350)
Luncheon (2 @ $4,000)
General Donation to Support the Program
Directory/Program Sponsor ($1,000)
Sponsorship Levels:
Dinner Sponsor ($3,000) Audio/Visual Sponsor ($750)
Beverage(2Carts
Luncheon (2 @ $2,000)
@ $4,000) Gift Basket Sponsor
Directory/Program ($350)($1,000)
Sponsor
General Donation to ($750)
Support the Program
rous donation will Sponsor
Dinner be acknowledged
($3,000) as follows: Audio/Visual Sponsor
Beverage Carts (2 @ $2,000) Gift Basket Sponsor ($350)
Announcement during the program and signage during the event
General Donation to Support the Program
NameYour generous donation will be acknowledged as follows:
listed in the 2020 Golf Outing Program
• Announcement during the program and signage during the event
Kids’Your
Chance of PA
generous
• Name website
donation
listed will
in the recognition
be2020
acknowledged with link to your website
asProgram
Golf Outing follows:
• • Announcement during
Kids’ Chance of the program
PA website and signage
recognition with linkduring
to yourthe event
website
• Name listed in the 2020 Golf Outing Program
• Kids’ Chance of PA website recognition with link to your website
X
g Signature
Authorizing Signature Date Date
X
Kids’ Chance
Authorizing of Pennsylvania, Inc., thanks you and your organization for your willingnessDate
Signature to sponsor services at the 2020 Golf
nce of Outing
Pennsylvania, Inc., thanks you and your organization for your willingness to sponsor services at the
to benefit PA students in need! Please complete this agreement and send it directly to: Kids’ Chance of PA, 1231
Kids’
benefit PAChance
Highland of Pennsylvania,
students
Avenue, in need!
Fort Inc., thanks
Please
Washington, you and
complete
PA 19034. your
Any organization
this agreement
questions for Lloyd
contact your
andwillingness
send
Brown todirectly
sponsor services
at: itLBrown@stumarinv.com
to: Kids’at the 2020 Golf
Chance of PA,
Outing to benefit PA students in need! Please complete this agreement and send it directly to: Kids’ Chance of PA, 1231
Avenue, Fort Washington, PA 19034. Any questions contact Lloyd Brown at: LBrown@stumarinv.com
Highland Avenue, Fort Washington, PA 19034. Any questions contact Lloyd Brown at: LBrown@stumarinv.com
Kid’s Chance of Pennsylvania, Inc.
1231 Highland Ave., Fort Washington, PA 19034
p. 215-302-3598
Kid’s Chance of Pennsylvania, Inc.
Kid’s1231
e.Chance ofFort
Pennsylvania,
Washington, PA 19034 Inc.
info@kidschanceofpa.org
Highland Ave.,
p.www.kidschanceofpa.org
215-302-3598
1231 Highland Ave., Fort Washington, PA 19034
e. info@kidschanceofpa.org
p. 215-302-3598
www.kidschanceofpa.org
e. info@kidschanceofpa.org
www.kidschanceofpa.orgANNOUNCING KEYNOTE SPEAKER:
Latrisha “Lolly” Bentch, Patient Liaison for
Pennsylvania Department of Health’s
Office of Medical Marijuana
Medical Marijuana – Where Are We Now?
Lolly Bentch, Patient Liaison
Pennsylvania Department of Health
Tuesday, June 4, 2019
1 p.m. – 2:15 p.m.
Chocolate Ballroom
*Unless indicated otherwise, the views and opinions expressed by the speakers
in any presentation are solely those of the speaker and do not necessarily
represent the position or opinion of the Bureau of Workers’ Compensation, Office
of Adjudication, Appeal Board or Department of Labor & Industry.
Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program
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