HIGHLIGHT & COPY THIS REGISTRATION FORM and PASTE it into your word processing program. Print out a copy and fill in all the information requested. Attach your registration and CSAC Exam fee, check or money order made payable to ACADC in the amount of $325. This fee includes your registration with ACADC as your chosen certification organization, your CSAC Exam, and your CSAC I Certification Fee. Mail it to: ACADC Institute, PO Box 8604, Redlands, CA 92375 – If you have questions or need information you may contact us at Tel. 877-478-5756 / 909-795-5655, or email: acadc@acadc.org or visit our website at www.acadc.org
Certification Course Registration Form
NAME__________________________________________________________________________
ADDRESS_______________________________CITY________________________ZIP________
DAY PHONE ______________________ EVENING PHONE______________________
EMAIL __________________________________ LAST 4 DIGITS SSN# __ __ __ __
CREDENTIAL PROGRAMS AND TUITION FEES (Please check the program(s) or course(s) for which you are registering
[ ] CSAC I Exam - Certified Substance Abuse Counselor CSAC I Designation - Exam Fee: $325 (Includes registration fee and CDAAC application fee)
[ ] CSAC II - Supervision / Field Experience & Research Paper - Tuition $325
[ ] Certified Drug, Alcohol & Addictions Counselor Certification (CDAAC) Designation - 155 classroom hours required for state certification - Tuition $1450
[ ] Transcript Review - $25
[ ] ACADC Institute Charter / Institute Administrator Training - Charter fee $1500
[ ] Certificate Endorsement (Circle what applies ): Marriage & Family Counseling / Mental Health Counseling / Social Work - $325 per Endorsement
[ ] I am interested in learning about professional degree programs in Christian Drug, Alcohol & Addiction Counseling including the Associate of Ministry, Bachelor of Ministry, Master of Ministry and Doctor of Ministry Degrees.
Call 877-478-5756 toll free for further information
I understand that the certifications and degree programs for which I am hereby enrolling are granted under the authority of the Association of Christian Alcohol & Drug Counselors in collaboration with Potter's Bible College and Theological Seminary, and will be subject to the Association's ethical standards described in it's code of conduct. I understand that upon completion of all program requirements, I will be granted the certification or degree for which this application is made. I acknowledge that all tuition & fees paid go to the work of the Association of Christian Alcohol & Drug Counselors and are non-refundable. I understand that in addition to classroom attendance, it is my responsibility to know and meet all state requirements for certification. I agree to take no legal action against the Association of Christian Alcohol & Drug Counselors or any individual minister, counselor, educator or employee associated with the Association of Christian Alcohol & Drug Counselors.
Student’s Signature: ____________________________________________________
Dated on the _________ day of the month of ______________________, 2006.
I am including a check or money order made payable to ACADC in the amount of: $__________________ Please consult above checklist for your total tuition fee.
