National Council Of Certified Dementia Practitioners

National Council of Certified Dementia Practitioners® 1 A Main Street Suite 8 Sparta, NJ 07871-1909

Toll Free 1- 877-729-5191 1-973-729-5191 www.nccdp.org [email protected] Application for Certification as Certified First Responder Dementia Trainer ™ CFRDT ™

PLEASE PRINT OUT AND SEND WITH THE FOLLOWING INFORMATION.

PLEASE PRINT OR TYPE. IF HAND WRITING, USE BLACK OR BLUE INK ONLY. PLEASE NOTE THAT THE APPLICATION PROCESS TAKES APPROXIMATELY 4-6 WEEKS.

DO NOT FAX THIS APPLICATION. IT MUST BE MAILED TO THE NCCDP.

Price: For Private Trainings Please contact [email protected] or 877 729 5191 CFRDT can only be scheduled by a group such as a city, county, state or national First Responder organization. If this is a scheduled program please list Name of Organization: ______Scheduled Date of CFRDT Training: ______Price: Please see your organization for details.

(If you are a NCCDP CADDCT Certified Alzheimer's Disease Dementia Care Trainer you are only required to complete the application. There is no live class for NCCDP CADDCT’s. The price is $500.00 for CADDCT Trainers only)

Please allow six weeks to receive your products. The power point presentation will be emailed to you. Student notebook and instructor notebook will be mailed to you.

What is included: Power Point, Master Hand out Notebook and instructor notebook and Certificat ion as a CFRDT.

You may not copy the power point or instructor notebook. You may not distribute the power poin t in any manner including but not limited to electronic.

May we place your name (not your address) on the NCCDP CFRDT directory website? Please check one. Yes ___ No___

Updated 3/15/2017 Please check all that apply to you.

First Responder Profession

Police Officer ______Firefighter ______Red Cross Worker ______EMT/EMS: ______CADDCT Instructor: ______College Educator: ______Technical learning institution: ______Other: ______

General Standards: . College Graduate. The degree must be from an Accredited College or University. . or / Graduate degree from an accredited College or University or Nurse.  Complete the CFRDT application - Must work directly for a First Responder Learning Institution providing education to Law Enforcement, EMT, Fire Fighter, Training Academy, etc. OR (CADDCT Trainers You must complete the CADDCT class first)  Must have at minimum one year experience educating First Responders or health care professionals.  The certification is for two years. At which time, you will need to renew your certification. You will receive a notice in the mail (2 months prior to the deadline) of your upcoming renewal. The renewal fee as of 5/7/2014 is $100.00 and is subject to change.

The fee includes an 1) Instructor manual which cannot be copied in any format. 2) Power Point which will be emailed to you and can only be copied to your lap top and a memory stick one time. Cannot be copied for any other purpose than for the one CFRDT trainer to use. 3) Master Student Alzheimer's Disease and Dementia Care Notebook. Must be photo copied at the NCCDP web site. The master student notebook includes the student application to apply for CFR-DT Certified First Responder - Dementia Trained within 30 days of the class.

Updated 3/15/2017 I have read and understand the general standards requirement.

Sign and Date: ______*********************************************************************** General Information:

Name: Last______Middle: ______First:______

Credentials to be listed after your name: ______

Home Address:______

City:______State:______Zip Code:______

Personal Email Address______

Home Phone Number: Area Code ( ) ______- ______Cell Phone: Area Code ( ) ______- ______

EMPLOYMENT HISTORY

Name of Organization/Employer: ______

What is your position/title: ______

Length of Employment: Month and Year: ______To ______

Please check one: Full time:______Part Time:______Volunteer: ______

Supervisor Name and phone number: ______

Work Address:______

City:______State:______Zip Code:______

Work Email Address: ______Work Phone Number: Area Code ( ) ______- ______Describe your teaching experience: ______

Updated 3/15/2017 EDUCATION: College/University/ attended:______Address:______Dates Attended: From (month/yr) ______Graduated: ( month/yr) ______Major: ______Degree(s) Awarded and Date(s)______

If you are a CADDCT Please Provide Your NCCDP CADDCT Number.

______

NCCDP Notarization Instructions:

The applicant personally appeared and stated upon oath this ______day of ______that the information contained therein is true and correct.

I, the applicant, attest that all the information I have provided on this document is correct and true.

Signature of Applicant: ______

Notary Public in and for the State of ______

Signature of Notary: ______

Name of Notary: ______

Phone Number: ______

Commission Expires: ______

Place Notarization Seal Here.

Applicant’s Signature and Date:

______Date: ______

Updated 3/15/2017 Make sure to include with your application… (These documents will be kept on file and will NOT BE RETURNED TO YOU!)

 A copy of the certification NCCDP CADDCT Alzheimer’s Disease Dementia Care Train number if applicable.

 Copy of college diploma or if a Nurse a copy of the state registry showing you are current with your license.

 Add email to send receipt if paying by credit card.

 Application Notarized.

 Completed and signed applications.

 Signature on Application.

 Signature on General Standards.

 Payment

Updated 3/15/2017 BE SURE TO MAKE A COPY OF THE ENTIRE APPLICATION AND KEEP FOR YOUR RECORDS.

How to Appeal

If you are not awarded a certification and you wish to appeal, please write a letter to:

NCCDP Executive Appeal 1 A Main Street Suite 8 Sparta, NJ 07871-1909

You must send a typed letter that includes: Your name, address, phone number, reason for denial and why you are appealing the decision. The NCCDP Executive Appeal will reach a decision after reviewing you’re application. All decisions reached by the Executive Appeal are final. Please allow 6 weeks to process.

Updated 3/15/2017 Price: $500.00

If paying by Check: Please make checks payable to NCCDP

If paying by Credit Card please complete the following information. Upon receipt of application there is a 300.00 cancellation fee. Please allow 4 weeks to process refund.

Returned Check Fee: There is a $17 fee for returned check.

Cancellation must be in writing sent via certified mail signed receipt within 48 hours of order. Once product has shipped there is no refund.

Credit Card Information: Type of Card: Please check: Visa ____ MC ____ AX ____ Debit: ____ Discover: ____

Number: ______Name on Card: ______Expiration Date: ______

Address where bill for this card is mailed: ______

Zip Code: ______

Email address: ______

I hereby give permission for the NCCDP to charge my card or debit card in the amount of $______

Signature: ______

Date: ______

Email: ______

Updated 3/15/2017 Replacement fee for the CFRDT ADDC Power Point Curriculum is $450.00 which will be emailed to you. You may only order one replacement copy.

Replacement fee for the CFRDT Instructor manual replacement fee is $450.00 which will be mailed to you. You may only order one replacement copy. You may not distribute nor duplicate the instructor manual nor the ADDC power point curriculum in any format using any means. You must be in good standing to order a replacement copy.

Updated 3/15/2017 Please tell us how you heard about NCCDP : Please check all that apply.

Received a NCCDP Fax about an upcoming seminar

Received a FAX OR BROCHURE from an approved NCCDP trainer about an upcoming seminar

Read about it in a newspaper, magazine, online social network or blog. Please indicate the name: ______

Heard about it in class or association. Which association? ______

Searched the Internet

Received NCCDP newsletter

NCCDP LinkedIn. If LinkedIn which group?

NCCDP Face Book

NCCDP Twitter

Friend / Co Worker

Board member: Which Association? ______

Association state, national conference or International Conference. Which Conference? ______

I heard about you because of NCCDP Alzheimer's disease and dementia Staff Education Week press release.

Other? Please explain:______

I don't remember

PLEASE RETURN ALL PAGES OF THE CDP APPLICATION.

Updated 3/15/2017