Professional Activity Certification Training "PACT" REGISTRATION FORM (Please print)
Name: ________________________________________________
Address: _____________________________________________
City, State, Zip Code: ____________________________________
Email: ________________________________________________
Telephone:
Home: ___________________ Work: ____________________
Cell: ____________________ FAX: _____________________
Facility: ______________________________________________
Facility Address: _______________________________________
Years of Activity Experience: _______
PACT Start Date: _______________ (Participants have 1 year to complete the program) (After 1 year you must pay $150.00 to reactivate your program for another year.)
I understand that I must complete all 9 mandatory sessions (in any order of choice) - initials _____
Mandatory Sessions: (5 hours each) 1) Activity Professional 101,
2) Adapting Recreational Programs, 3) Documentation - General,
4) Documentation - Specific, 5) Programming, 6) Regulatory Compliance,
7) Resident/Family Council, 8) Surviving Surveys and 9) Therapeutic Programs
I understand that I must complete 3 supporting sessions (select your choices) - (participants also have an optional to purchase all supporting sessions) -
initials _____
Supporting Sessions: (must complete 3) (5 hours each)
1) Budgeting, 2) Calendar Development, 3) Community Resources, 4) Culture Change/Person Centered Care, 5) Interdepartmental Relations, 6) Paper Crafts, 7) The Functions of Management, 8) Volunteer Management and
9) Your Client -The Aging Senior
Registration Fee: $59.00 for each session, if paying for all 12 sessions at the beginning $649.00. If participants want all 18 sessions $769.00.
Shipping & Handling: Participants who receive their materials via email there is no shipping and handling charges. However, if you request to have the materials mailed to you there is a fee of $3.50 per session.
I understand that in order to obtain national certification I am expected to have a certain amount of activity experience and educational level. Upon verification of this I will be required to pass a national examination. Initials ________
Activity Experienced Needed: Bachelors degree - 1 year; Associate degree - 2 years; 12 semester college credits - 3 years; High School diploma - 5 years
________________________________________________
Applicant Signature and Date: ____________
All applications must be received with payment for at least 4 sessions ($59.00 x 4 = $236.00) to show a commitment to this program. Make checks payable to Collins Healthcare Education, Inc. - mail to PO Box 780251, Orlando, FL 32878-0251 www.collinshealthedu.com
For information call (407) 282-9647 or fax information to (407) 737-8840
Participants who are paying for their program online using PayPal - must pay the following amounts as listed which include a service charge for convenience.
One Session - 5 Hours - PACT
One five hour session as part of the PACT program.
$
62.00
Twelve Sessions - 5 Hours each - PACT
It is mandatory that all participants complete at least 12 sessions.
$
670.00
Eighteen Sessions - 5 Hours each - PACT
If the participant wants to obtain all eighteen sessions of the PACT program.
$
795.00
Shipping and Handing - PACT
If participants want the sessions mailed to them, then the participant must pay a shipping and handling charge for each session. If sessions are emailed to the participant then there is no charge.
$
4.00
Initial Payment for the Payment Plan - PACT
Participants wanting to participate in the payment plan must make a initial payment of $245.00 (the amount for four sessions) to show a commitment to the program.
$
245.00