• Montessori Dementia Capable Certification Participant Form

    Thank you for your interest in a training program with CaringKind.  We look forward to enhancing your skills to support individuals and families impacted by dementia. If you would like to reschule dates please call the Helpline at 646-744-2900 or email Helpline@wearecaringkind.org. 

  • Which session would you like to attend?
  • Format: (000) 000-0000.
  • What is your geographic location?*

  • Demographic Information

    As a part of our reports for certain funders, we are required to provide additional information on our clients. We ask that you spend a few moments answering the questions below. At CaringKind, we are committed to safeguarding your privacy.  Any reported information will NOT be associated with your name or any other identifying information. Please note - questions include the option, "Prefer to not answer".
  • What is your gender?*
  • What is your ethnicity?*
  • What is your military status?*
  • What is your race?*

  • If you have questions about how your data is shared, please contact our Chief Evaluation and Grants Officer, Dr. Ed Cisek at ecisek@cknyc.org or by calling 646-744-2953.

  • Photo, Video & Story Consent 

    CaringKind shares photos, videos, and personal stories to build public understanding of Alzheimer's disease and related dementias, and to raise the funds that support our programs — including care consultations, support groups, our Helpline, and community education and training. Your voice and image, if you choose to share them, help other families see they are not alone and help donors understand the impact of their support.

    With your permission, CaringKind may use photos, video, audio recordings, quotes, stories and experiences in the following materials: fundraising appeals and donor communications; our website and social media channels; newsletters and brochures; educational and training materials for professionals and the public; and press or media coverage of CaringKind's work.  Information may be identified with your role (e.g. family caregiver, person living with cognitive changes, care provider) and first name (unless you provide permission for your full name to be used).

    CaringKind will not sell your name, image, or story to a third party, and will not use it for any purpose other than those listed above.

    You may withdraw this consent at any time, for any reason, by contacting CaringKind's Marketing Department at (646) 744-2900 or info@wearecaringkind.org. Withdrawing consent will stop future use, but CaringKind cannot recall materials already printed, broadcast, or posted.

  • Please check the box below to confirm your agreement with the above Photo,Video & Story Consent statements. You will authorize your electronic signature at the end of the page:*

  • Payment

    The cost will be $75 to ADRC an affliate of CaringKind plus the cost of the Certification through the Montessori Center. You can also purchase separately a NCTRC Micro Credential Digital Badge and Loyola University CMC CEU's.

  • Please check the box below to confirm your agreement regarding payment. You will authorize your electronic signature at the end of the page:*

  • Participant Agreement

  • I understand CaringKind is committed to safeguarding my privacy. To help CaringKind measure and enhance the quality of their services, I will complete questionnaires related to my program. My responses will only be reviewed by service-related staff and program evaluators. My responses may be shared anonymously for testimonials, but I will not be personally identified outside of CaringKind without my permission. I also understand that programs may be video/audio recorded for internal training and quality assurance purposes only. CaringKind will not publicly share any video recordings without my additional authorization. 

    I recognize the value of CaringKind’s services and commit to fully participating in the service being provided to me. I will attend all service sessions as planned unless an unexpected conflict arises. If I need to cancel an appointment, I will provide a minimum of 24 hours’ notice and will contact my service provider directly or through the CaringKind Helpline at: 646-744-2900. 

    I am voluntarily participating in CaringKind's services and I or my successors will not hold CaringKind, its Board of Directors, volunteers, and/or staff liable for any injury or damages due to my own negligence or compromised physical/cognitive abilities. I will also arrange for my own assistance with care and transportation needs before/during/after my program as I understand CaringKind staff/volunteers will not be able to assist with my personal care needs (including using the restroom, public transportation, etc.) unless a formal arrangement has been made in advance. 

  • Please check a box below to confirm your agreement with the above statements and authorize your electronic signature below:*
  • Today's Date*
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  • PWD
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