Sponsoring Organization:

Address:  

City:     State:     

Zip Code:

Program/Activity Title: 

Actual Number Of Clock Hours Of Training (Excluding Welcome Remarks, Meals, Breaks, Exhibits, Poster Sessions, Business Meetings, and Social Hours):

 Location:                            

Date(s) of Training:   

Instructors:

Method/Type Of Instruction

Training Audience

LVTs  O&Ms   VRTs  TVIs Other

Training Level:

Beginner  Intermediate  Advance

Documentation To Be Submitted With The Application

Check the items to indicate that it will be sent to the ACVREP office.

One copy of the promotional material, such as direct mail flyers or marketing brochures

An outline or agenda, if not contained within the promotional material, to include a breakdown of clock hours.

A description of the program's content areas, including learning goals and objectives. Objectives should be measurable and specific and should state what the participant is expected to learn.

The Planning/Peer Review Committee Attestation Form (see Appendix A).

A description of your procedure for verifying attendance. This procedure should include a way to verify attendance for the full session, for example, a sign-in/sign-out sheet with written instruction that the individual sign in and sign out for each session. If you are hosting a conference, attendance will need to be verified at each workshop.

A copy of the evaluation form that each participant will complete after the program/activity (see Appendix B in the CE application packet).

A brief summary of the program/activity to put on ACVREP’s website (see Appendix D in the CE application packet ). This should include the program/activity date(s) and location, number of approved CE hours, and the name and phone number of the contact person. Please note that ACVREP reserves the right to modify the summary as needed.

 Does your organization have a financial interest in the products or techniques used in this continuing education course:  
      Yes  No   If yes, please send a list of such products and/or techniques to the ACVREP Office.
    
Submittal of the annual CE application fee ($75.00), which is non-refundable, and the appropriate offering fee(s). Please see pages 9-10 of the CE application packet for a list of offering fee(s). You can either send a check or money order to ACVREP (it should be in U.S. dollars and made payable to ACVREP) or if you would rather pay by debit/credit card (Visa or MasterCard), please contact the ACVREP office at 520-887-6816, as this is not a secure site. The ACVREP office will need the following debit/credit card information:

• Your name, exactly as it appears on the card
• Debit/Credit card number
• Billing address
• Expiration date
• Amount authorized to charge to card

Please note: A service fee of $25.00 will be assessed for all checks returned for insufficient funds or for charges made to closed accounts. Also, please note that if the application is not approved, the offering fee will be refunded.

Relation To Approved Content Areas

The program/activity must apply to one or more of the following approved content areas. A full listing of these thirteen areas is provided in the CE application packet. Please check the area(s) that apply to the program/activity for which you are seeking approval.

The Visual System And Vision Loss
The Auditory System And Hearing Loss
Psychosocial Aspects Of Visual Impairment
Professionalism In Vision Education And Rehabilitation
Professional Information
Individuals Who Are Visually Impaired With Additional Disabilities
Aging And Vision Loss
Sensory Motor Functioning
Human Growth And Development Over The Lifespan
Assessment Of Persons With Visual Impairment And Their Environments
Instructional Methods
Development, Administration, And Supervision Of Programs Serving Persons With Visual Impairment
Communication, Team-Building, Consumerism, Cultural Diversity, And Working With Families

Statement Of Understanding

I hereby certify that I have read, understand, and agree to abide by the requirements as stated within this application and ACVREP’s Continuing Education Policy and Procedures document. Furthermore, I certify that I have completed the application and attached the required documentation. I understand that no program/activity will be reviewed unless accompanied by the required documentation and the appropriate non-refundable processing fee. I understand that ACVREP reserves the right to monitor programs/activities for which it has granted continuing education approval and to withdraw such approval from any program/activity that is offered or presented in any manner that is inconsistent with the approval requirements. I also understand that any approval granted for this program/activity is valid for only one year from the date of approval. If the program/activity is changed in any way during that year, I agree to seek approval from ACVREP. The sponsoring organization, , agrees to restrict the use of the ACVREP approval statement to the program/activity named on this application, to provide each ACVREP certificant with documentation of attendance, and to keep a roster of attendees on file for a five-year period. I understand that the program must be held in an accessible, barrier-free location. I have read the Codes of Ethics for each of the ACVREP certification programs (CLVT, COMS, CVRT) and certify that the CE program/activity that is offered by this organization does not advocate any practice that would be in violation of the Codes, nor of any standard of professional behavior for ACVREP certificants. All three Codes of Ethics can be found on ACVREP’s website (www.acvrep.org) under the “Downloads” page.

Contact Person   

Title                  

Date