Register for AFA Partners in Care: Supporting Individuals Living with Dementia” Live Training Name* First Last Email* Phone*Billing Address*Due to increased security measures, please use the exact address that is on your bank account. Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code How did you hear about AFA’s training?AFA websiteAFA mailing (postcard or e-mail)AFA publication (e-newsletter or AFA Care Quarterly)AFA social servicesEmployer/colleagueFriend/family memberNewspaper/magazine/TV or radioSocial Work Contact Hours I would like to obtain 6 social work contact hours for participation in this training. Contact hours will be awarded following successful completion of the AFA Partners in Care: Supporting Individuals Living with Dementia training. AFA Dementia Care Partner certification is available following completion of the examination. AFA Partners in Care is approved by New York State Education Department’s State Board for Social Work for 6 contact hours. The Alzheimer’s Foundation of America, Inc. SW CPE is recognized by the New York State Education Department's State Board for Social Work as an approved provider of continuing education for licensed social workers #0222. This program is approved by the National Association of Social Workers (Approval #886446769-3742) for 6 Social Work-Pain and Symptom Management continuing education contact hours. *Note: New Jersey, Idaho, and Oregon do not currently recognize NASW National Approval. Applications can be submitted to NASW State Chapters. Michigan and West Virginia do not accept National CE Approval Programs and require individual program/provider application processes."AFA Partners in Care: Supporting Individuals Living with Dementia” Live Training*Wednesday, December 12, 2018 – 9am-4pm EST - $95Wednesday, January 23, 2019 – 9am-4pm EST - $95Friday, March 1, 2019 – 9am-4pm EST - $95Wednesday, May 8, 2019- – 9am-4pm EST - $95Cancellation Policy for all Educational Programming:*AFA’s encourages participants to make every effort to attend the event for which they have registered. All refunds for educational programming, including training and workshops, are subject to a $30.00 administrative processing fee. Refunds will not be given for no-shows.I have read and agree to the termsCredit Card American ExpressDiscoverMasterCardVisa Card Number Expiration Date Month010203040506070809101112 Year20182019202020212022202320242025202620272028202920302031203220332034203520362037 Security Code Cardholder Name Total $0.00 CAPTCHA
Register for AFA Partners in Care: Supporting Individuals Living with Dementia” Live Training Name* First Last Email* Phone*Billing Address*Due to increased security measures, please use the exact address that is on your bank account. Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code How did you hear about AFA’s training?AFA websiteAFA mailing (postcard or e-mail)AFA publication (e-newsletter or AFA Care Quarterly)AFA social servicesEmployer/colleagueFriend/family memberNewspaper/magazine/TV or radioSocial Work Contact Hours I would like to obtain 6 social work contact hours for participation in this training. Contact hours will be awarded following successful completion of the AFA Partners in Care: Supporting Individuals Living with Dementia training. AFA Dementia Care Partner certification is available following completion of the examination. AFA Partners in Care is approved by New York State Education Department’s State Board for Social Work for 6 contact hours. The Alzheimer’s Foundation of America, Inc. SW CPE is recognized by the New York State Education Department's State Board for Social Work as an approved provider of continuing education for licensed social workers #0222. This program is approved by the National Association of Social Workers (Approval #886446769-3742) for 6 Social Work-Pain and Symptom Management continuing education contact hours. *Note: New Jersey, Idaho, and Oregon do not currently recognize NASW National Approval. Applications can be submitted to NASW State Chapters. Michigan and West Virginia do not accept National CE Approval Programs and require individual program/provider application processes."AFA Partners in Care: Supporting Individuals Living with Dementia” Live Training*Wednesday, December 12, 2018 – 9am-4pm EST - $95Wednesday, January 23, 2019 – 9am-4pm EST - $95Friday, March 1, 2019 – 9am-4pm EST - $95Wednesday, May 8, 2019- – 9am-4pm EST - $95Cancellation Policy for all Educational Programming:*AFA’s encourages participants to make every effort to attend the event for which they have registered. All refunds for educational programming, including training and workshops, are subject to a $30.00 administrative processing fee. Refunds will not be given for no-shows.I have read and agree to the termsCredit Card American ExpressDiscoverMasterCardVisa Card Number Expiration Date Month010203040506070809101112 Year20182019202020212022202320242025202620272028202920302031203220332034203520362037 Security Code Cardholder Name Total $0.00 CAPTCHA
