ICCCP(F) APPLICATION

GF ICCCP Fellowship (F) Application Form

Note: If you are already a Registrant or have an account on CVRP.net, please login before submitting this form.

"*" indicates required fields

Application Completion

Please note if you are already credentialed in life care planning, you do not need to submit a redacted life care plan. However please assist us by writing the examination. An application is considered to be incomplete until all information has been received & the fee paid. A current Certificate of Errors & Omissions/Liability Insurance must be received to finalize application for a credential. Due to COVID-19 CVRP is accepting soft copies of VSPC/PC but reserves the right to request a hard copy.

Contact Information & CVRP Website Profile

Name*

First Last

Residential Address*

Street Address Address Line 2 City Province / State Postal Code / ZIP Country

Personal Phone*

Personal Other Phone

Personal Email*

Your personal email is used to recover passwords and to initially login to cvrp.net. Once your first credential is approved, your Registration # will become your CVRP Username.

Password*

Enter Password Confirm Password

Strength indicator

A) Please attach confirmation of possession of CLCP or CCLCP or other life care planning credential in good standing: &

Max. file size: 100 MB.

B) I am willing to complete the ICCCP examination in order to provide assistance in peer validation of the examination

The grade achieved from the examination does not affect your ability to achieve the ICCCP(F) credential. The examination is currently in beta for peer review to collect a substantial sample size. A successful ICCCP(F) applicant will be awarded 12 ICCCP CEUs for participation in life care planning examination in beta version. The credential will be awarded to the applicant once the examination is completed.

In addition 3 of the following 6 categories must be met.

C) Please attach confirmation of testimony as an expert witness in court in successfully defending life care plan(s): &/or

Max. file size: 100 MB.

D) Please attach proof of publication of a peer-reviewed article in a recognized publication; &/or

Max. file size: 100 MB.

E) Please attach proof that you taught life care planning certification-related courses at or through a recognized institution; &/or

Max. file size: 100 MB.

F) Please attach proof that you made presentations as a subject matter expert at recognized conferences where a minimum of 8 certification education maintenance credit hours in total were awarded (including credit for speaker preparation hours) or would be eligible for awarding of CEUs; &/or

Max. file size: 100 MB.

G) Please attach proof that you have experience in doing peer-reviewing for life care planning credentialing; &/or

Max. file size: 100 MB.

H) Please attach proof that you have participation in life care planning examination question development; &/or

Max. file size: 100 MB.

The candidate is eligible for the ICCCP Fellowship, if candidate meets 3 of the 6 criteria for Fellowship as detailed in items “c” through “h” above.

Employer Information

Employer Name*

Address*

Street Address Address Line 2 City Province / State Postal Code / ZIP Country

Work Phone

Work Cellular Number

Work Email*

Current Position*

Regardless of outcome, have you ever been the subject or recipient of a complaint of professional negligence through membership in a professional association or registration in a related field?*

Yes

If yes please explain:

Are you now the subject of any type of investigation, inquiry or proceeding by a professional licensing body or professional association relating to your professional conduct, competence, capacity or any other aspect of your professional practice?*

Yes

If yes please explain:

Are you aware of any facts, circumstances or situations which may reasonably give rise to a complaint other than noted above?*

Yes

If yes please explain:

Document Upload

Current Curriculum Vitae or Resume

Max. file size: 100 MB.

Vulnerable Sector Police Check

Max. file size: 100 MB.

Vulnerable Sector Police Check Expiry

Professional Liability Certificate

Max. file size: 100 MB.

Liability Certificate Expiry

Birth Certificate/Passport or other official government picture ID

Max. file size: 100 MB.

Are you interested in performing peer reviews &/or exam question development?

Yes

Registrants can earn 12 CEUs (including ethics) per year.

Application Declaration

I agree to the declaration

I hereby verify that the information submitted for this application is accurate. I understand that providing false or incomplete information could result in action being taken by the College affecting my registration status of certification of registration. I confirm that it is my obligation to notify the College within 30 days if any information changes.
I confirm that I have not been charged or convicted of a criminal offence, for which I have not received a pardon.
I confirm that I have not been dismissed from employment or refused membership in a professional association or registration in a related regulated field, on the grounds of professional misconduct.
I agree to annually review the CVRP Standards of Practice, & CVRP By-Law. I undertake to abide by all the rules, regulations, standards, & policies of the College. I understand that my registration in the College is voluntary & that by becoming a Registrant, I consent to the College acting as my professional self-regulating body. I recognize that the College has the right to limit or terminate registered status under the College’s Bylaw, Policies or Standards of Practice.
As a voluntary Registrant, I hereby release the College from all liability for any act of negligence or want of ordinary care on the part of the College & or any of its agents. In consideration of my registration in the College, I waive, release, & discharge the College & their directors, officers, agents & members, their representatives, heirs, executors & assigns from all claims of liability. This agreement is binding upon my executors, heirs, & assigns. I hereby discharge & release from any liability, the College, & its authorized representatives, for any acts, communications, or decisions regarding the processing, consideration, & maintenance of registration.
I hereby declare that I have valid liability insurance coverage for the duration of my registration. I understand that I must submit proof of continuing education units required to maintain my level of certification.
I hereby declare that the information given in this application & any attached/forwarded document(s) is, to the best of my knowledge, true, correct, & complete in every respect

Fees

Application Processing & Examination Fee: $290.00 + HST or GST, according to Province/State of Residence, due on submission.

Price:

Tax

$ 0.00 CAD

(Alberta, British Columbia, Manitoba, Northwest Territories, Nunavut, Quebec, Saskatchewan or Yukon)

Tax

$ 0.00 CAD

(Ontario)

Tax

$ 0.00 CAD

(New Brunswick, Newfoundland and Labrador, Nova Scotia or Prince Edward Island)

Tax

$ 0.00 CAD

(Foreign)

Total

Credit Card*

Card Details

Cardholder Name

This field is for validation purposes and should be left unchanged.

ICCCP(F) APPLICATION

GF ICCCP Fellowship (F) Application Form

Application Completion

Contact Information & CVRP Website Profile

Employer Information

Document Upload

Fees

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