Application for Intermediate Certification Form

  • Member Information

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Employer Information

    Complete only if changed from Registration for Certification.
  • Education Information

    Complete only if changed from Registration for Certification.
  • Date Format: MM slash DD slash YYYY
  • Candidates Chosen Focus Areas

  • Please indicate the four focus areas in which you were examined for Intermediate Certification.
  • It is the responsibility of the exam candidate to arrange for the exam to be supervised by a supervisor or Agency Administrator. Please indicate who will be supervising your intermediate exam.
  • Please give minimally 30 days notice of exam date:
  • Date Format: MM slash DD slash YYYY
  • Your exam supervisor will receive instructions regarding the supervision and return of the exam.
  • Candidates Acknowledgement

    I attest that the information provided is true and complete to the best of my knowledge. I understand that misrepresentation could result in decertification by The Child and Youth Care Association of Alberta.
  • Drop files here or
    Please upload a signed copy(ies) of the "Endorsement of Supervisor and Agency for Certification Maintenance" document.
  • Price: $ 135.00 CAD

Please ensure that you have met the requirements for application for intermediate certification:

  • Current membership on file
  • Completed registration for certification on file
  • Completed and signed Application for Intermediate Examination form enclosed
  • Endorsement of Supervisor and/or Agency for Certification Examination(s) enclosed
  • Intermediate certification date on file
  • Examination fee $135.00 payment or receipt enclosed.

Upon receipt and confirmation of information provided, you will be contacted with instructions to proceed with the Certification Process.

Personal Information Protection

The information requested in this form is collected under the Personal Information Protection Act for Child and Youth Care Association of Alberta internal use only.  No information contained in this form will be disclosed to any other individual, group, or agency as per the Confidentiality Policy of the Child and Youth Care Association of Alberta.  Questions concerning this collection should be directed to cycaa@telus.net.