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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