The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

PFvSED2JgwNSbtH9NgVD4pX7wRDyngYUFb8gmtQMaf7EpILEd2uQrnVfkvA86TgKxRohAWQQkybhAQiVnCBCk3wFGVCbKBM5UHIy5F9WfygHZHSS

MM Trainer Registration/Renewal

Please complete the form below. Please note that your form will not be processed if any area is missing. After the survey you will be redirected to a "registration page". This is how you will pay for your renewal or your original registration. If you are not transferred to the payment page upon completion please visit: https://vcuagewaveevents.virginiainteractive.org/Home/Search/102

Original registration to become a 32-hour medication management trainer is $40. Trainer renewal is $12. If you have a letter from the Board of Nursing that certifies you as a 68-hour trainer, please contact our office (AGINGSTUDIES@VCU.EDU) to request a $10 coupon off your registration.

Once you complete this form and payment you will receive a certificate by EMAIL in 8-10 business days.

Thank you!

Name

* must provide value

Is this for a renewal or original application?

* must provide value

Renewal

Original Application

reset

Email (please keep in mind that this will be the email address that certificates will be emailed to)

* must provide value

Street Address

* must provide value

City/State/Zipcode

Phone Number

* must provide value

Please select which license you currently hold

* must provide value

LPN

Pharmacist

reset

License Number

* must provide value

License Expiration Date

* must provide value

M-D-Y

Please attach a copy of your license here

* must provide value

Upload file

Employer

* must provide value

Employer Address

* must provide value

Employer Phone

* must provide value

For which state agencies do you train medication aides? (Check all that apply)

* must provide value

Department of Social Services

Department of Education

Department of Juvenile Justice

Department of Corrections

Department of Behavioral Health and Developmental Services

Do you have a letter from the Board of Nursing authorizing you to teach the 68 hour curriculum?

* must provide value

Yes

reset

Please upload a copy of your Train-the-Trainer certificate here

* must provide value

Upload file

Date(s) of Train-the-Trainer course

* must provide value

School/Location and trainer name

* must provide value

Expand

Please upload a copy of your Train-the-Trainer certificate here

* must provide value

Upload file

Clock hours for Train-the-Trainer

* must provide value

CEU's for Train-the-Trainer

* must provide value

Do you currently offer a medication aide Train-the-Trainer course?

Yes

reset

Payment Method

* must provide value

Credit/debit (you will be redirected to payment page once you submit this form)

*WE ARE CURRENTLY NOT ACCEPTING CHECKS AT THIS TIME* Check (Please notify us at agingstudies@vcu.edu if you are mailing a check)

reset

Paid? OR Check # (FOR OUR OFFICE USE ONLY)

Certificate Expiration Date (FOR OUR OFFICE USE ONLY)

Certificate Email Date (FOR OUR OFFICE USE ONLY)

M-D-Y

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