National Council of Certified Dementia Practitioners



National Council of Certified Dementia Practitioners®

55 Main Street, Suite 102

Sparta, NJ 07871-1909

Toll Free 1- 877-729-5191 1-973-729-5191



NCCDPCORPORATE@

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 NCCDPCORPORATE@ 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 Certification as a CFRDT.

You may not copy the power point or instructor notebook. You may not distribute the power point 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___

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) A master student handout notebook is provided to the trainer. Additional student handout notebooks can only be ordered with NCCDP through the Trainer portal. Student handout notebooks cannot be copied.

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____________________________________________________

PERSONAL E-MAIL ADDRESS IS MANDATORY. IF YOU DO NOT HAVE A PERSONAL E-MAIL ADDRESS, PLEASE GO TO ANY E-MAIL COMPANY OF YOUR CHOOSING SUCH AS AOL, YAHOO, GMAIL, ETC., AND CREATE A FREE ACCOUNT. MOST E-MAIL COMPANIES OFFER A COMPLIMENTARY E-MAIL ACCOUNT. WE WILL NOT PROCESS YOUR APPLICATION WITHOUT AN PERSONAL E-MAIL ADDRESS. YOU CAN NOT USE YOUR SUPERVISOR OR ANOTHER COWORKERS E-MAIL 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:________

Last 4 digits of your Driver’s license or state issued identification: _____________________________

Work Email Address: ______________________________________________________

Work Phone Number: Area Code ( ) ______________ - ________________________

Describe your teaching experience: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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: ___________________________________________

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

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

55 Main Street, Suite 102

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.

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 $35 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: _______________________________________________________

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.

Please tell us how you heard about NCCDP: Please check all that apply.

θ Received a NCCDP Fax about an upcoming seminar

θ Received a FAX OR BROCHURE from an approved NCCDP trainer about

an upcoming seminar 

θ Read about it in a newspaper, magazine, online social network or blog.

Please indicate the name: _____________________________________________

θ Heard about it in class or association. Which association? ____________________

θ Searched the Internet

θ Received NCCDP newsletter

θ NCCDP LinkedIn. If LinkedIn which group?

θ NCCDP Face Book

θ NCCDP Twitter

θ Friend / Co Worker

θ Board member: Which Association? ______________________________________

θ Association state, national conference or International Conference.  Which

Conference? _________________________________________

θ I heard about you because of NCCDP Alzheimer's disease and dementia Staff

Education Week press release.

θ Other? Please

explain:_______________________________________________________________________________________________________________________________________________________________________________________________________________

θ I don't remember

PLEASE RETURN ALL PAGES OF THE CDP APPLICATION.

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