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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 I Exam fee, check or money order made payable to ACADC in the amount of $330. This fee includes your registration with ACADC as your chosen certification organization and upon completion of the CSAC I Entrance Inventory, makes you an ACADC Member. It also includes your CSAC I inventory, and your CSAC I Certificate 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, or email: acadc@acadc.org or visit our website at www.acadc.org
Name__________________________________________________________________________
Address_______________________________City________________________Zip___________
Day Phone ___________________________ Evening Phone_____________________________
Email ______________________________ Last 4 digits of Social Security #: xxx-xx- __ __ __ __
Drivers License # ____________________________________
Date of Birth ______________________________ Place of Birth __________________________
Site Location - City:_______________________________State:___________________________
AVAILABLE CREDENTIAL PROGRAMS AND TUITION FEES (Please check the program(s) or course(s) for which you are registering):
[ ] CSAC I Entrance Inventory - Certified Substance Abuse Counselor CSAC I Designation - Fee: $330 (Includes registration fee and CDAAC application fee)
[ ] CSAC II Internship - Supervision / Field Experience - Fee $330
[ ] Certified Drug, Alcohol & Addictions Counselor Certification (CDAAC) Designation - 155 classroom hours required for state certification - Tuition $1540
[ ] Transcript Review – Fee $25
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 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.
[ ] I certify that I am not a 290 offender.
[ ] I certify that I am a 290 offender.
Explanation: _____________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Student’s printed name: __________________________Student’s Signature__________________________
Dated on the _________ day of the month of ______________________, 2007.
Witness: _____________________________________________________ Title:________________________
***Your check or money order is your receipt
**************************BELOW FOR OFFICE USE ONLY**************************
Check or money order received from ________________________________________________________ and made payable to ACADC in the amount of: $___________________ Check # ____________________
Received by: _____________________________________________ Date: _________________________
Date mailed to ACADC main office: _____________________________ By: _________________________
Invoice #: ________________________________________________Date: _________________________
Rev 5/07
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