Assisted Living Facility Training Provider Application

Assisted Living Facility Training Provider Application

ATTENTION:

You must upload documented proof of your education and teaching/practical experience to receive approval. Examples include: diplomas, official transcripts, RN license, signed letters from employer(s) on letterhead with teaching dates and topics, etc.

All file uploads must be labeled appropriately by indicating what their content contains to undergo the review process. For example, your education or RN license should be labeled “RN License, Diploma, Transcripts, etc.” and your experience should be labeled “Teaching Experience_Supervisor Letter, Training Certificate, etc.”

If any mislabeled files are included in your submission, then your application will be deleted from our records without further correspondence.

If you do not upload supporting documentation for ALL of the qualifications selected within your application, then you will receive an emailed notice that your submission will be deleted from our records and you will need to re-apply.

The contents of this online application form are written in accordance with DOEA Form ALF/ADRD-001.

Full Application Submission

ATTENTION: If you received an approval number issued by the University of South Florida prior to July 1, 2023, then you do not need to re-apply. Training provider approvals do not expire. When presenting your training materials, please be sure to provide the care setting with your approval letter. Additional qualifications may fall under 456.025 F.S

Name Prefix*

Select

First Name*

Last Name*

Phone Number*

Phone

Email*

Company Name*

Do you work for a company with multiple locations?*

Select or enter value

Company Address*

If you answered 'yes' to working for a company with multiple locations, please enter the address where you work, or the company's primary address.

City*

State*

Select

ZIP Code*

County*

If you are an out-of-state applicant, please select that option from the drop-down list.

Select

What is your public service area (PSA)?*

(Your PSA is based on which county you are in.)

If you are an out-of-state applicant, please select that option from the drop-down list.

Select

Eligibility Requirements:

Please select your level of education:*

Note: If you have a Master's degree in a healthcare, human service, or gerontology-related field from an accredited college or university, you qualify without needing the additional teaching or practical experience below.

You MUST upload documentation for the chosen education level.

Select

AND one that applies:*

You MUST upload supporting documentation for the chosen criteria.

I have a Master's degree in a healthcare, human service, or gerontology-related field from an accredited college or university

≥ one year of teaching experience for caregivers of persons with ADRD

≥ three years of practical experience providing direct care to persons with ADRD

Completion of a training program in ADRD from a university or an accredited health care, human service, or gerontology continuing education provider (≥ 4 hours), AND ≥ two years of practical experience providing direct care to individuals with ADRD

Please use the file upload box below to submit all required documentation.*

If you do not upload supporting documentation for ALL of the qualifications selected within your application, then you will receive an emailed notice that your submission will be deleted from our records and you will need to re-apply.

All file uploads must be labeled appropriately to undergo the review process. If any mislabeled files that do not indicate what their content contains are included in your submission, then you will receive an emailed notice that your submission will be deleted from our records and you will need to re-apply.

Drag and drop files here or

IMPORTANT:

By submitting this application, I certify I have carefully read its contents and all the provided information is true and correct to the best of my knowledge. If this application was submitted incorrectly, meets none of the stated requirements, or does not have an associated curriculum, I understand it will be automatically disapproved.

Submitting this application is hereby representative of my electronic signature.

Send me a copy of my responses

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