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Request for Information

  • If you would like more information regarding the Dementia Professional Certification, complete the fields below.

  • Please allow at least 10 business days for a response.

  1. Last Name:
  2. First Name:
  3. Middle Initial:
  4. Date of Birth:
  5. Mailing Address:
  6. City:
  7. State:
  8. Zip Code:
  9. Daytime Phone Number:
  10. E-mail Address:
  11. I prefer to be contacted by the following:
    Regular Mail
    Telephone
    E-mail
  12. Questions/Comments:

Contact dementia-cert-app@lists.ivytech.edu for assistance.