Please Read Before Submitting:

• You must know your test score from all 4 modules before submitting
• To submit online you must be prepared to pay $10.00 with MasterCard or Visa (Quickest Method for Processing)
• To submit without using credit card:
  • Complete the Form
  • Under Payment Information - Change Pay by check to yes
  • Leaving Other Payment Information Blank
  • Click on Submit
  • After submitting, a page will appear with your information
  • Print the page
  • Write a $10.00 check made out to the Eastern NC Chapter Alzheimer's Association
  • Mail Page and Check To:
    
    Alzheimer's Association
    Eastern North Carolina Chapter
    400 Oberlin Road, Suite 220
    Raleigh, NC 27605
    

Continuing Education Credit Application

E-mail address (required):

Your Name:

Title:

Mailing Address:



City State & Zip:

Day Phone:

Facility:

Position

Date Completed:

Module 1 Score: /10
Module 2 Score: /10
Module 3 Score: /10
Module 4 Score: /10

Please Count The Hours As:

3.5 Hours Toward Initial Orientation
3.5 Hours of Dementia Continuing Education

Attestation:

I hereby declare that I have viewed the 3.5 hour DVD, Accepting the Challenge: Providing the BEST CARE for PEOPLE with Dementia and finished all the test review questions. *you must score at least 70% in each section to receive continuing education credit for this content

Attestation of Viewing & Passing
Comments:




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