CDCM Renewal Form

National Council of Certified Dementia Practitioner LLC
103 Valley View Trail, Sparta, NJ 07871
877 729 5191 Toll Free
www.nccdp.org

DO NOT FAX IN THE RENEWAL APPLICATION FORM

CDCM and CDP Renewal Application
for Golden Living employees only

THIS APPLICATION IS FOR CURRENT CDCM’S and CDP’s APPLYING FOR RENEWAL OF THEIR CERTIFICATIONS.

CDCM $100.00 CDP $100.00 BOTH MUST BE PAID TO RENEW YOUR CDCM CERTIFICATION.	$200.00
Late fee if application is not post marked by the time your CDCM and your CDP certification expire.	additional $10.00

Instructions:
This form must be completed for consideration for re-approval as instructor and CDP.
Major credit cards accepted.

Check here if, your original CDCM & CDP was approved as a Golden Living employee. If so, you renew for CDCM and CDP. ONLY GOLDEN
LIVING DEMENTIA UNIT MANAGERS RECEIVED THE CDCM AND CDP CERTIFICATION.


First Name:
Middle Initial:
Last Name:
Personal Address
Home address:
City:
State:
Zip Code:
Home Phone:
Cell:
Email Address:
Has your name changed in the last two years?	Yes No
If yes, what was your previous name?
Has your home address changed in the last two years? If yes, please be sure that the above address is your current address.	Yes No
Employment Info
Are you still employed with Golden Living?	Yes No
If No, Year you left
Employment & Company Name:
Your Position/Title:
Work Address:
City:
County:
State:
Zip:
Work Email Adddress:
Company Web Address:
What type of community do you work for?
If Other, Please list
Do you currently manage or supervise a dementia unit?	Yes No
If yes, how many beds?
Do you supervise staff?	Yes No
If yes, how many staff do you supervise?
If NOT EMPLOYEED, are you currently looking for a job?
If OTHER, please explain.
Please list previous experience if currently not working:

Licensure Info
Are you currently certified or licensed in a health care profession?	Yes No
Initials (not your title) after your name: Ex. ADC, RN, LCSW, CNA
Are you currently in good standing with your other license or certification? Ex. RN, LPN, CNA	Yes No
List the license or certification numbers:
What state holds your license or certification?	Yes No
What government agency or certifying body do you have your license or certification with (Example NCTRC)?
Tool Kit
Have you downloaded the free staff in-services for NCCDP Alzheimer’s dementia Staff Education Week Feb 14-21 free tool kit and free staff in-services which are available November till March?	Yes No
If no, will you download the free information?	Yes No
If No, Please explain:
Registry
I acknowledge that my name will be placed on the NCCDP CDCM & CDP registry located on the web site. YOUR ADDRESS WILL NOT BE SHOWN ON THE WEB SITE!	Your Initial:

Code of Ethics National Council of Certified Dementia Practitioners Code of Ethics for Certified Dementia Practitioners (CDP®)
The CDP provides services to the health care profession with respect and dignity to the Dementia Client. The CDP recognizes and respects the Dementia Client individuality. The CDP participates in ongoing education and stays current with regards to Dementia issues and the National Council of Certified Dementia Practitioners Body of Knowledge. The CDP maintains competence in his chosen profession. The CDP will report to the National Council of Certified Dementia Practitioners any acts by a Certified Dementia Practitioner that is illegal or unethical. The CDP assumes absolute responsibility for your own individual actions. The CDP will stay current with certifications with the National Council of Certified Dementia Practitioners. The CDP insures the privacy of the dementia client and applies all HIPPA Regulations. The CDP works to implement innovative ideas to the health care setting that may help a Dementia Client. The CDP works to insure that quality of life is provided for the Dementia Clients residing in your health care setting. The CDP networks with other health care professionals, attends Dementia / Alzheimer’s Seminars, Conventions, Support Groups and Ethics Committees. The CDP respects the Dementia Clients customs, religious beliefs, and philosophy. The CDP is truthful and avoids providing false or misleading Information. The CDP will not use the National Council of Certified Dementia Practitioners on any brochure or advertising without the express permission of this organization and in no way benefit directly or Indirectly at the expense of the National Council of Certified Dementia Practitioners. The CDP understands that its certification with the National Council of Certified Dementia Practitioners does not in any way confer upon the CDP any type of licensure as a health care provider.
Print your name to indicate that you have read the Code of Ethics:

You are required to complete 10 hours of Continuing Education on any health care related topic within 24 months of your renewal date: You are not required to mail in the certificates with the CDCM & CDP renewal application.
Statement that you have completed the required 10 hours of Continuing Education:
I have successfully completed 10 hours of continuing education (any health care related topic) for the last 24 month period for the two year certification since my certificate last renewal. I certify that the information put forth on the CDCM Certified Dementia Care Manager renewal / recertification and CDP renewal application is true and complete to the best of my knowledge. I further acknowledge that if the information supplied on this form is willfully false, I am subject to disciplinary sanction, including certification suspension/ revocation. Please write your name below indicating everything you have stated in the renewal application is true:
Your name:

Do not send verifying documentation with this form. You are to maintain your certificates of CE or CEU’s for three years following renewal, certificates documenting successful completion of Continuing Education (CE) showing the date and title of the CE program, the number of Continuing Education Units (CEU’s) or contact hours awarded and a certifying signature or other certification of the approved provider. A random audit of CE completion is periodically conducted to verify the preceding statement. The CDP or CDCM professional selected for the audit must provide these original documents to the NCCDP by the deadline specified by the NCCDP audit notice.