NCCAP Continuing Education Form
For those individuals that have attended an NCCAP Chat, and would like one hour of continuing education credit, simply print and complete the form and send it along with a $10.00 fee (check or money order) to:
NCCAP
P.O. Box 62589
VA Beach, VA 23466
|
Name
|
_____________________________________ |
|
Phone #
|
_____________________________________ |
| Address | _____________________________________ |
| _____________________________________ | |
|
Email address
|
_____________________________________ |
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Date of the
chat you attended
|
_____________________________________ |
| "Screen" name used during chat | _____________________________________ |
|
Moderator of
the chat
|
_____________________________________ |
|
Topic / title
of the chat
|
_____________________________________ |
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Synopsis or
summary of the chat (50 - 100 words):
|
continue on back if necessary |
Upon receipt of the completed form, processing fee, and confirmation of attendance from the chat moderator - a completed certificate of attendance will be issued from the NCCAP office.
| ___________________ | _____________ |
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Signature
|
Date
|
Below to be completed by the NCCAP office only:
| _____________________ | __________________ |
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Moderator Confirmation
#
|
Signature of
Approval
|