NCCDP National Council of Certified Dementia Practitioners

Global Leader in Dementia Education and Dementia Certification

1 A Main Street Suite 8
Sparta, NJ 07871-1909 USA

Within USA Toll Free 1- 877-729-5191 Answering Service
International Calls 1 973.729.5191 Answering Service

1.973.729.6601 NCCDP Office 1.973.860.2244 FAX

www.NCCDP.org

CADDCT® Certified Alzheimer’s Disease and Dementia Care Trainer®

Certification Application and CADDCT Seminar Application to become

CADDCT Certified Alzheimer’s Disease and Dementia Care Trainer

"One CADDCT Trainer Impacts The Quality of Care Provided by Thousands of Health Care Professionals, Front Line Staff and Students Who Provide Care to Our Most Vulnerable Elderly."

NCCDP Lynn Biot Gordon MSW LCSW CDP CADDCT

Chief Operations Officer Founder

NCCDP Sandra Stimson CALA ADC AC-BC CADDCT CDP CDCM

Chief Executive Officer Founder

You are applying to attend the NCCDP seminar. In order to be approved and certified as a NCCDP Certified Alzheimer’s Disease and Dementia Care Trainer CADDCT you must attend and complete the 1 day Certified Alzheimer’s Disease and Dementia Care Trainer CADDCT Certification seminar. The seminar is a one day class but may be offered over two days. Check the schedule carefully.

Please print out entire application, complete the entire application and mail the entire application to be considered for the Certified Alzheimer’s Disease and Dementia Care Trainer certification CADDCT seminar. Please mail the entire application to the above address with your payment. (If, you are a Dementia unit manager working in an Assisted Living or Nursing Home community, you may also be interested in CDCM Certified Dementia Care Manager certification. Please click on certifications and Dementia Unit Manager CDCM tab to download the CDCM application.) You must complete CADDDCT first before applying for CDCM.

DO NOT FAX IN: We recommend sending your packet signed receipt and to utilize a service such as FEDEX or UPS. If this is a last minute registration please scan in or fax to 19738602244. We do NOT recommend scanning in the credit card form if you are paying by credit card. Please scan in all other documents if you’re a last minute registration all by the credit card form and call the NCCDP office directly with the credit card information. If faxing in, you can fax the credit card form with the application. If you are scanning in or faxing in, please notify NCCDP at . If you are mailing in the application using FEDEX or UPS or Postal Service Certified Mail please note the office is not open on weekends.

If, you are approved for the CADDCT Certified Alzheimer’s Disease and Dementia Care Trainer certification seminar, you will be sent via your work email address, an acknowledgement package. The acknowledgement packet will include homework assignments and two different contracts, a license agreement and instructor agreement. The acknowledgement packet is scanned to your work email address only.

If you are not approved and you paid by check a refund check will be sent to you. If you are paying by credit card the payment will not be processed unless you are approved for the seminar. The application and supporting documents will not be returned. If you are not approved you will be notified by mail or email. Refunds will take 4 to 6 weeks to process. There is a 35.00 returned check fee for bounced checks. Payment is expected at the time your application is submitted to the NCCDP.

Be sure to check all pages to insure you have completed all areas and signed all required areas of the Certified Alzheimer’s Disease and Dementia Care Trainer CADDCT pre-registration application.

Upon completion of the CADDCT seminar you will be awarded the certification designation of CADDCT Certified Alzheimer’s Disease and Dementia Care Trainer® and Certification as CDP® Certified Dementia Practitioner ®. You will also receive all training materials in the seminar.

Who Should Attend CADDCT Certified Alzheimer’s Disease and Dementia Care certification seminar:

The CADDCT Certified Alzheimer’s Disease and Dementia Care certification seminar is recommended for In-service Directors, Nurse Educators, Corporate Trainers, Nurses, Social Workers, Dietitians, Physicians, Activity Directors, CTRS and Recreation Therapists, Psychologists, Psychiatrists, Dementia Unit Managers, Surveyors, Department Heads, Health Care Organization / Company Owners, Management Company Trainers, Administrator’s, Rehab Directors, OT, PT, Speech, Medical Directors, State Surveyors, AOA Trainer, Ombudsman Trainers Consultants, Pharmacists, Support Group Leaders and Clergy who are responsible for training health care professionals, front line staff and volunteers who work in Nursing Homes, CCRCs, Assisted Living, Adult Day Care, Home Care Agencies, Hospitals, Retirement Homes, Senior Communities, Rehabilitation Centers, Psychiatric Facilities, Senior Centers, Retirement Communities AOA, State Ombudsman Office’s, Associations, Government Agencies, Visiting Nurse Agencies and, Hospice Agencies. The CADDCT seminar is also open to college professors and trainers teaching health care courses and degree programs for trade schools, colleges and learning institutions.

Qualifications: To apply for the CADDCT seminar and become a NCCDP CADDCT Certified Alzheimer’s Disease and Dementia Care Trainer, YOU DO NOT NEED TO BE A CDP® PRIOR TO ATTENDING THIS SEMINAR. The applicant must meet the following criteria:

1. Certified or licensed in a health care profession OR/ Master level education or PhD.

2. 4 Year college degree or graduate degree from an accredited college or RN, LPN, LVN or NP.

3. A minimum of 5 years experience in a health care related field / profession OR an educator in a learning institution.

4. Minimum of 1 year’s experience presenting in-services or seminars to health care professional and front line staff in a geriatric setting OR presenting health care curriculum to students enrolled in a health care profession at a learning institution.

There are always exceptions to the rule, if you do not fit into the criteria, please call NCCDP to discuss your options.

Your application will be reviewed and if you are approved for this seminar you will receive written acknowledgement. Written acknowledgement is e-mailed to your work e-mail.

The acknowledgement packet will contain two homework assignments which must be completed and returned to the NCCDP before the class date and also brought to class. The home work consists of a sample brochure and a sample class certificate. Instructions for the home work will be contained in the acknowledgement letter. The acknowledgment packet will also contain two contracts which are the license agreement and an instructor agreement. These documents must be signed by a notary and returned to NCCDP before the start of the class. You should make a copy of these documents once signed by a notary for your records. The license agreement and instructor agreement deal with intellectual property rights, copy right and trademark concerns as it pertains to the NCCDP curriculum.

CFO asks CEO, “What happens if we invest in developing our people and then they leave us?”
CEO: “What happens if we don’t, and they stay?” ~Peter Baeklund

“While certification promotes and maintains quality, it does not license, confer a right or privilege upon or otherwise define the qualifications of anyone in the healthcare field."

PLEASE TYPE DIRECTLY ONTO THIS APPLICATION. Return the entire application to NCCDP. You may fax to 19738602244 or you may mail the application “signed receipt” via UPS, FEDEX or US Postal Service. We recommend overnight delivery. NCCDP is closed Saturday and Sunday and will not accept deliveries on the weekend.

Date: ______

The Power Point Curriculum, Instructor Manual and Student handout notebook is available in English or Spanish. Please indicate which version you are requesting. Only one language type is provided in the CADDCT class price. You may purchase additional student handout notebooks in either language through the instructor only part of the web site, once you are a certified CADDCT trainer.

If you require an extra curriculum set in either Spanish or English, the cost $150.00. You may not order a duplicate set in the same language.

Please Check One: I am requesting ___English versionor ____ Spanish version.

Please write the training date and the seminar location here:

Date: ______City and State: ______

NOTE: Once you sign up for the CADDCT seminar and you cancel, there is a $750.00 cancellation fee. If you cancel 7 days prior to the event there is no refund. We will allow you to move to another location one time without penalty. We make no guarantees that the next location you sign up for will not be cancelled due to poor attendance. In which case we will offer you other locations. It will be your responsibility to notify the NCCDP of the replacement location and date of training in writing.

Name: Last: ______First: ______Middle Name: ______

Your name will appear exactly like this on your NCCDP certifications except in reverse order.

List all license, certifications or registrations credentials that you hold? Example: CTRS, LCSW, RN

______

Are all your credentials current? Yes ____ No ____

Your name and credentials will appear on the NCCDP web site under instructor, and or CDCM and CDP registries. (If you are a Dementia Unit Manager working in an assisted living or nursing home community and you also wish the CDCM certification please go to our site and click on certification and CDCM. You are welcome to sign up for both classes at the time you submit your CADDCT registration for.)

Home Address: ______

City: ______State: ______Zip Code: ______

Country: ______

International Students Only: Please use this space, if you need extra space for your address______

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

Cell Phone: Area Code: ( ) - ______- ______

International Students Only: What is your country code: ____

Personal Email Address: ______

Emergency Contact Name: ______

Emergency Contact Phone Number: Area Code ( ) - ______-______

Drivers license or state issued identification: ______

Employment History:

Company Name: ______

What type of business? Ex. Nursing Home, Hospice, Home Care, Private Management

______

Your Position / Title: ______

Your Supervisors name, title, phone number and email address?

______

I understand that my supervisor may be contacted to verify employment? Initial here: ____

Company Address: ______

City: ______State: ______Zip Code: ______

Work Phone: Area Code: ( ) - ______- ______

Your work email: ______

Company Web Address: ______

Are you part of a chain or franchise, if so what is the corporate name? ______

What college did you graduate from (Highest level)? Under graduate ___ Masters __ PhD ___

Name of College:______

Year You Graduated: ______

Degree (s) Awarded: ______

Credentials: List all your licenses, certifications, registrations, etc. List the name of the governing body that awarded you the license, certification, registration, etc. List the state that holds your license, certification or registration. List the Expiration Date. Include other Alzheimer’s / Dementia certifications also.

ATTACH a copy of at least one license, certification or registration credential.

Example: ADC- NCCAP – TN- 2016

______

ALL OF THE CREDENTIALS THAT YOU LISTED WILL APPEAR AFTER YOUR NAME ON THE INSTRUCTOR AND CDP REGISTRY LOCATED ON THE NCCDP WEB SITE. :

Please describe your current position duties:

______

Please list in-services or seminars that you have presented live and in person:

Date: ______Topic: ______

*ATTACH A SAMPLE SEMINAR OR IN-SERVICE THAT YOU HAVE PRESENTED LIVE.

What experience do you have working with Dementia patients?

______

What other Alzheimer’s Disease and Dementia seminars have you attended?

Date: _____ Topic: ______

ACKNOWLEDGEMENT THAT I WILL RECEIVE NCCDP LICENSE AGREEMENT and NCCDP INSTRUCTOR AGREEMENT UPON ACCEPTANCE INTO THE CADDCT CERTIFIED ALZHEIMER’S DISEASE AND DEMENTIA CARE TRAINER CERTIFICATION SEMINAR:

Please note that each trainer is required to sign a NCCDP Instructor Agreement / License Agreement prior to starting the class. Both documents require a notary. The NCCDP Instructor Agreement / License Agreement will be e-mailed to each applicant upon receiving the Certified Alzheimer’s Disease and Dementia Care Trainer seminar pre-registration application, approval of applicant and processing of full payment.

The NCCDP License Agreement deals with NCCDP intellectual property and specifically states that none of the training materials can be copied in any format, how the class can be taught, etc. The NCCDP InstructorAgreement also deals with intellectual property, copy right issues, conduct, expectations’ of the trainer, student handout notebooks requirement, CDP applications, advertising your classes, etc.

You are required to order extra copies of the student handout notebook from the NCCDP web site, unless other copying methods have been approved by the NCCDP.

Trainers will never collect the CDP applications, nor collect the CDP application fee nor approve CDPcertification. Only the NCCDP credentialing body can approve applicants who are applying for and qualify for the distinguished designation and certification CDP Certified Dementia Practitioner. Further, anyone can take the NCCDP Alzheimer’s Disease and Dementia Care seminar by an approved NCCDP Alzheimer’s Disease and Dementia Care Trainer but not all students qualify for CDP certification. You are required to point to the application in the student handout notebook at every seminar. Other than that, any questions a student may have should be directed to the NCCDP.

The agreements do not require that the trainers pay any additional fees to NCCDP for any money that the trainer collects for your advertised ADDC seminars that“you” the trainerpresents. Some trainers elect to only teach for their facility or agency where the trainer is employed, while others advertise and teach privateseminars where the student pays the trainer directly for the ADDC Alzheimer’s Disease and Dementia Care seminar.

You are required to advertise all seminars on the NCCDP web site seminar calendar page, regardless if the seminar is open to the public. There is no charge to advertise on the NCCDP calendar web page.

If you want to discuss or preview the agreements prior tomailing in your CADDCT preregistration form and payment, please contact NCCDP for more information.

THE CONTRACTS AND HOMEWORK ASSIGNMENTS MUST BE RETURNED BEFORE THE CLASS DATE. IF THEY ARE NOT RETURNED BEFORE THE CLASS DATE, YOU WILL NOT RECEIVE YOUR PRODUCTS NOR YOUR CERTIFICATIONS. YOU WILL BE ALLOWED IN CLASS BUT YOU WILL NEED TO BRING YOUR OWN PAPER FOR NOTES.. If WE HAVE TO SHIP YOUR PRODUCT TO YOUR WORK ADDRESS, AFTER THE CLASS DATE, YOU WILL BE RESPONSIBLE FOR FEDEX CHARGES.