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252366 1 2/08/1 5 ��C.Iq . Jr® L'•, CITY OF CARMEL, INDIANA VENDOR: 370124 ONE CIVIC SQUARE N C T R C CHECK AMOUNT: $""'•'105.00' s. �r�; CARMEL, INDIANA 46032 7 ELMWOOD DRIVE CHECK NUMBER: 252366 +,;,�'ON�� NEW CITY NY 10956 CHECK DATE: 12/08/15 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 1091 4341999 59095 105.00 OTHER PROFESSIONAL FE I _ NCTRC 7 Elmwood Drive CTRS RECERTIFICATION New City,NY 10956 U call (845) 639-1439 APPLICATION fax (845) 639-1471 email nctrc@NCTRC.org www.NCTRC.org �15 I Q131 / 15 Date of Application: p Certification Number. CRecertification Due Date: Name as it appears on ID Current Full Mailin g Address ► l I r� V Cit-'7 -Atate Province / V Zi Postal Code L/ Count 5A Work Phone(include area code)'l' / ^5�3—5'Ase Phone(include area code) Ul —�5l'_l -7— 7 -5 � �� a o ca r z-Y,el c 1 coir Fax Number(include area code Email Address Con. N CTRC RECERTIFICATION OPTIONS: Summarize the areas of Recertification Requirements you have earned on this page.There are two options for obtaining recertification: OPTION 1:Continuing Education and Professional Experience Continuing Education(A minimum of 50 hours required in this areal • Continuing Education Conferences and Workshops • Academic Courses • Professional Publications and Presentations Professional Experience(A minimum of 480 hours required in this areal ❑OPTION 2:Reexamination(You must submit the Exam Registration form and fee by the posted deadline to use this option) Reexamination may only be taken during the last scheduled exam prior to recertification expiration date. Date of Reexamination: Payment Options:NCTRC accepts Credit Cards,Checks and Money Orders in US funds.Please fill out the appropriate selection: ElAnnual Maintenance ($80) +Recertification($25) =Total of$105 (Required for all recertification applications) ❑Reinstatement Fee$25(first year of inactivity)/$50(years 2-5 of inactivity) ❑CREDIT CARD I iCHECK QMONEY ORDER ❑ Visa ❑ MasterCard ❑ American Express Name as it appears on card: + Card Number: 1'4 -7 -`73•-y c-24 Expiration Date: By signing below I do hereby authorize NCTRC to charge$ to the above Visa/MasterCard/American Express Account Signature(required): Date: NCTRC©f F7ISM USE ONI T ate Received Amohupt andED"a'tetPat'd Date of Initial Review j Process 4- t_ Recerti"fyt Y'es No { New Receinficarion;Date Page 2,02/15 CONTINUING EDUCATION job Analysis Knowledge Codes: Conferences and Workshops:Continuing Education includes professional FKW Foundational Knowledge workshops,conferences and other formal programs.List the total number of ASP Assessment Process hours obtained in your five year cycle.Your continuing education content DOC Documentation must relate to one of the knowledge areas of the NCTRC Job Analysis. IMP Implementation Academic Courses:Academic coursework must be taken at a college or ADM Administration of TR/RT Service university. Publications:Articles,editorials,professional editing of textbooks,etc.,that relate ADV Advancement of the Profession to therapeutic recreation. Presentations:Presentations made at professional conferences,workshops or Please consult the NCTRC Certification programs. Standards,Part V:NCTRC Internship Supervision:An internship training that includes intense profession-National Job Analysis for further al training and results in documented student competence in the TR process. explanation of the codes. *MANDATORY SECTION: In submitting this NCTRC Recertification application, I attest that I have completed (total of 50 hours required): hours of continuing education,relating to the NCTRC Job Analysis Knowledge Codes. Letter codes: hours of academic coursework,relating to the NCTRC Job Analysis Knowledge Codes. Letter codes: _ hours of publications,presentations,&internship supervision (no more than 25 hours can be earned in these areas),relating to the NCTRC job Analysis Knowledge Codes. Letter codes: PROFESSIONAL EXPERIENCE Pertains to the Five-year Recertification Cycle:List your professional experience that was completed for a minimum of 480 hours within your five year certification cycle.Acceptable work experience must be in therapeu- tic recreation/recreation therapy as defined by the Job Task Areas of the Job Analysis.If more than one position or experience is used,include each position using the same format.If part time or volunteer,submit work verification. How would you best classify the professional experience you are submitting in TR/RT? (Select only the primary one) fherapist ❑Supervisor ❑Educator ❑Volunteer ❑Other Therapist/Supervisor ❑Administrator ❑Consultant ❑Student Agency Name.S4oY1e (�CA+ ACC Irl C_ Agency Phone include area code) AgencyAddress/City/State(Province)/Zip(Posta)Code/Country job Title Rroara )—n I/jgecCea-ko,-)rtI Name of Supervisor 5 Q_Yl S Supervisor's job Title L.; �c�G C� n I n ►j� I eck Employment:FromV (-) I Too V 1 G '1o3c5 Are you currently employed in this position? ❑Yes o DESCRIPTION: Please briefly describe your job duties in % of National Job Analysis the following categories derived from the NCTRC Job Analysis TIME Job Task Areas Task Areas for the above Professional Experience. Professional Relationships and Responsibilities e W& G , yl C Se rrna n a, cr5 Assessment Gt`JSrSS Z Cl_C hv -i '''C-0 n el 32 Plan Interventions and/or Programs GIYi`t Co� PO ro'117�Ga 6tSev neo U Implement Interventions and/or Programs tom'^ le vtn c K 4 O;e—0 Y, -0)'l e 5 ratw4 / Evaluate Outcomes of the Interventions and/or i-:\)Ct�aat_e �VvcroLqk Q SO�Se Programs �otC 1 v✓1 ►Y" V o+l�.of 'v v ' 00/0 St 0 Yl a-� o f Q V4-1 Document Intervention Services + t d�'1 G([ [t e 04 100/0 Treatment Teams and/or Service Providers ('Jo` t + i So e t U l c-I o Ct'ff5 l p S b,70' Develop and Maintain Programs J U • p Ct C e r �° Manage TR/RT ServicesO�J P — 5 Cv ice— Awareness e-Awareness and Advocacy e +O C- e 5 0 (C Fa l rs a &v *MANDATORY SECTION: In submitting this NCTRC Recertification application, I attest that I have completed (total of 480 hours required): 0 U 0 hours of professional work experience. CONTINUING EDUCATION job Analysis Knowledge Codes: Conferences and Workshops:Continuing Education includes professional FKW Foundational Knowledge workshops,conferences and other formal programs.List the total number of ASP Assessment Process hours obtained in your five year cycle.Your continuing education content DOC Documentation must relate to one of the knowledge areas of the NCTRC Job Analysis. IMP Implementation Academic Courses:Academic coursework must be taken at a college or ADM Administration of TR/RT Service university. Publications:Articles,editorials,professional editing of textbooks,etc.,that relate ADV Advancement of the Profession to therapeutic recreation. Presentations:Presentations made at professional conferences,workshops or Please consult the NCTRC Certification programs. Standards,Part V:NCTRC Internship Supervision:An internship training that includes intense profession-National Job Analysis for further al training and results in documented student competence in the TR process. explanation of the codes. *MANDATORY SECTION:In submitting this NCTRC Recertification application,I attest that I -Zhours pleted(total of 50 hours required): of continuing/Ied.u''catis�a,rely in to the NCTTR�Job Analysis Knowledge Codes. Letter codes: J ,1.M�✓ i C-X f 5 hours of academic cour wo k, elv g to the NCTRC Job Analysis Knowledge Codes. Letter codes: hours of publications,presentations,&internship supervision (no more than 25 hours can be earned in these areas),relating to the NCTRC Tob Analysis Knowledge Codes.Letter codes: PROFESSIONAL EXPERIENCE Pertains to the Five-year Recertification Cycle:List your professional experience that was completed for a minimum of 480 hours within your five year certification cycle.Acceptable work experience must be in therapeu- tic recreation/recreation therapy as defined by the job Task Areas of the job Analysis.If more than one position or experience is used,include each position using the same format. If part time or volunteer,submit work verification. How would you best classify the professional experience you are submitting in TR/RT?(Select only the primary one) ❑Therapist ❑Supervisor ❑Educator ❑Volunteer '❑Other OTherapist/Supervisor ❑Administrator ❑Consultant ❑Student 0 ec�c�a+��� 7 b Agency Name V S� Agency Phone include area code 3t7_ 64s �� A en Address Ci State rovince Zi ostal Code Count ,-- I u e job Title 7 n a n Pf' e C ac Q e-1 �?/u 166_+a Name ofSupervisoreJ`hrtll�l�(h � t.Jq�� Supervisor's job Title 1�.L� C�LtT1�)Yl '� P� Employment:From 0 J I V 00! 1 To ' � �� Y 3'60O Y 166 (r Are you currently employed in this position? es ❑No w �h CC PC DESCRIPTION Please briefly describe your job duties in % of National Job Analysis the following categories derived from the NCTRC Job Analysis TIME Job Task Areas Task Areas for the above Professional Experience. Professional Relationships and Responsibilities O i e..� ��c C e o i 'otn c,---- �; �!7 Assessment Plan Interventions and/or Programs Implement Interventions and/or Programs ''n C2 r✓I f G S�b n C� I Evaluate Outcomes of the Interventions and/or 5L1"V1v1 G 1`^ `��"� S0 � !cdr o Programs ' e[0 l e S 5 m - 1 �— `A e C iJ0,1+A 0.4- Document Intervention Servicespc i.t vine N (���e e ClG�/1 r�Q. to O Treatment Teams and/or Service Providers Develop and Maintain Programs 1 Ayr,v',,)e f�kl�t. <«'; CA}`u`'l Q�Gvrp�l Manage TR/RT Services t Su O 3t''ff Le5 1 e/ Awareness and Advocacy C- ik o V1 h7nr. �C; *MANDATORY SECTION:In submitting this NCTRC Recertification application,I attest that I have completed(total of 480 hours required): J 10 Q hours of professional work experience. pag ,02/15 DECLARATIONS—NCTRC PROCESSING AGREEMENT: NCTRC agrees to process your application subject to your agreement to the following terms and conditions. 1. To be bound by and in compliance with all NCTRC Certification Standards and rules relating to eligibility,re- newal and recertification,including,but not limited to,payment of applicable fees,demonstration of educational and experiential requirements,satisfaction of annual maintenance and recertification requirements,compliance with the NCTRC Grounds for Sanctions and other standards,and compliance with all NCTRC documentation and reporting requirements,as may be revised from time to time. 2. To authorize NCTRC to disclose,publish and/or release,in the sole discretion of NCTRC,any information regarding your certification or recertification application or status and any final or pending disciplinary decisions to state licensing boards or agencies,other health-care organizations,professional associations,employers or the pub- lic. 3. To hold NCTRC harmless and to waive,release and exonerate NCTRC,its officers,directors,employees,com- mittee members,and agents from any claims that you may have against NCTRC arising out of NCTRC's review of your application,or eligibility for certification,renewal,recertification or reinstatement,conduct of the examina- tion,or issuance of a sanction or other decision. 4. To only provide information in your application to NCTRC that is true and accurate to the best of your knowledge.You agree to revocation or other limitation of your certification,if granted,should any statement made on this application or hereafter supplied to NCTRC.is found to be false or inaccurate or if you violate any of the standards,rules or regulations of NCTRC. 5. To abide by the following testing conditions: A. NCTRC reserves the right to refuse admission to any NCTRC examination if you do not have the proper identification,or if administration has begun.If you are refused admission for any of these reasons or fail to appear at the test site,you will not be entitled to a refund or deferral of the application or examination fees. During the exam,the use of scratch paper,calculators,or reference to textbooks or notes is prohibited and you are not allowed to remove any exam materials from the administration room. B. NCTRC's examinations are only offered to individuals who are seeking NCTRC certification or recertifi- cation,and for no other purpose. NCTRC's exams and individual questions are copyright protected and highly confidential trade secrets. Any disclosure or reconstruction of test questions and content shall be a violation of NCTRC rules and subject to damages including,but not limited to,the cost of replacing the compromised question(s)and reconstruction of the exam,if advisable in the discretion of NCTRC. C. Proctors are authorized to maintain a secure and proper test administration.You may not communicate with other examinees during the examination.Any irregular,disruptive,inappropriate or sus ected cheat- ing behavior by you may result in your relocation or removal from the examination site and/por a refusal to release your examination scores;in such event,your examination fees will not be refunded or deferred. SIGNATURE:By signing,I acknowledge and affirm that I have carefully read and understand NCTRC's stand- ards,rules and requirements and that I agree to abide by these terms and to be bound by all of the provisions of the Declarations above. J'l 1 _l PRINTED Nom' :M t C�e1 lPSIGNATURE: DATE: l 1/ � / (L CONFIDENTIALITY RELEASE (Optional):I agree that NCTRC may release my name and any contact information on record with NCTRC to individuals and/or organizations for educational and/or research purposes. By signing this section,I understand that my name and address will be released on mailing labels requested by or- ganizations sponsoring educational programs,conferences,and special research studies. �11 Applicant Si gaaiure Dale Page 5.02/15 ACCOUNTS PAYABLE VOUCHER CITY OF CARMEL An invoice of bill to be properly itemized must show; kind of service,where performed, dates service rendered, by whom, rates per day, number of hours, rate per hour, number of units, price per unit, etc. Payee Purchase Order No. NCTRC Terms 7 Elmwood Drive New City, NY 10956 Invoice Invoice, Description Date Number (or note attached invoice(s)or bill(s)) PO# Amount 11/4/15 59095 NADTA Membership Inclusion'Supervisor 2016 xx3038 $ 105.00 Total $ 105.00 I hereby certify that the attached invoice(s),or bill(s)is(are)true and correct and I have audited same in accordance with iC 5-11-10-1.6 20 Clerk-Treasurer Voucher No. Warrant No. NCTRC Allowed 20 7 Elmwood Drive New City, NY 10956 ! In Sum of$ $ 105.00 ON ACCOUNT OF APPROPRIATION FOR 109 -Monon Center !. PO#or I Board Members Dept# INVOICE NO. .CCT#/TITL AMOUNT I I. 1091 59095 4341999 $ 105.00 I, I hereby certify that the attached invoice(s), or i bill(s) is(are)true and correct and that the materials or services itemized thereon for which charge is made were ordered and received except i December 1, 2015„ i Signature $ 105.00 Accounts Payable Coordinator Cost distribution ledger classification if �, Title claim paid motor vehicle highway fund i I