NCCDP - National Council of Certified Dementia Practitioners - Alzheimer's Training, Dementia Training and Professional Dementia Certifications NCCDP - National Council of Certified Dementia Practitioners - Alzheimer's Training, Dementia Training and Professional Dementia Certifications NCCDP - National Council of Certified Dementia Practitioners - Alzheimer's Training, Dementia Training and Professional Dementia Certifications NCCDP - National Council of Certified Dementia Practitioners - Alzheimer's Training, Dementia Training and Professional Dementia Certifications

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


 

 

 

 

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/Instructor/CDP Renewal Application

THIS APPLICATION IS FOR CURRENT CDCM’S APPLYING FOR RENEWAL OF THEIR CERTIFICATION.
 THIS RENEWAL APPLICATION MUST ACCOMPANY THE CDP RENEWAL APPLICATION. 

This CDCM renewal application is for NCCDP Certified Alzheimer's and Dementia Trainers ONLY who are also CDCM.

If you obtained your CDCM and CDP certification while employed or currently employed at Golden Living, please click here.

Renewal Fee: $100.00
Late fee if application is not post marked by the time your Instructor 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.

   
First Name:
Middle Initial:
Last Name:
Personal Address  
Home address:
City:
State:
Zip Code:
Home Phone: 
Cell:
Email Address:
Employment Info  
Employment & Company Name:
Present Position/Title:
Work Address:
City:
County:
State:
Zip:
Work Email:
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?
 
   

I acknowledge that my name will be placed on the NCCDP CDCM registry located on the web site.

YOUR ADDRESS WILL NOT BE SHOWN ON THE WEB SITE!

 Your Initial:
   

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 CE certificates with the CDCM renewal.


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 CDP Certified Dementia Practitioner renewal / recertification form and Instructor renewal application form 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 CDCM selected for the audit must provide these original documents to the NCCDP by the deadline specified by the NCCDP audit notice.  

 
 
 
Once you have completed the ONLINE CDCM renewal process, the NCCDP corporate office will mail you a new Instructor Agreement and License Agreement. These agreements need to be signed and returned to the NCCDP corporate office before your CDCM certification will be issued to you.

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