Write Clearly Using CAPITAL LETTERS and Tick Boxes Where Applicable

Annual Continuing Professional Development
Declaration and Exemption Form 2017/18
Please view instructions and guidance notes overleaf

Write clearly using CAPITAL LETTERS and tick boxes where applicable

Family Name: / First Name(s):
Membership ID: / Country:

Section 1 – please select one of the below options.

Before selecting your option please read the instructions and guidelines overleaf.

Option A - YES
¨ I have met the minimum of 20 hours of CPD requirement for 2017/18
Option B - NO
¨ I have not met my CPD requirement for 2017/18.
I understand that completing CPD is a requirement for retaining my teacher registration and sanctions do apply.
Option C – FULL EXEMPTION
¨ I have not been able to meet my CPD requirement for 2017/18 however, due to the circumstances outlined below and evidence provided, I believe that I am eligible for a Full Exemption (20hour) for 2017/18
Option D – PART EXEMPTION
¨ I have met at least 10 hours of CPD requirement (Time-Valued and/or Independent) for 2017/18, however due to the circumstances outlined below and evidence provided, I believe that I am eligible for a Part Exemption (10 hour) exemption for 2017/18.
Section 2 – If you selected Option C or D above, please complete Section 2.
All information provided will be treated confidentially and with upmost sensitivity.
Provide the reason(s) that you are applying for a full (20hour) or part (10hour) exemption:
Provide details of the documentation enclosed to support your application:
Section 3
I confirm that the information I have given in this form is true to the best of my knowledge, and I understand that I may be selected at random to participate in an annual CPD Audit. If selected I will provide evidence of my CPD activity. I understand that failure to do so, or submission of a false declaration is a breach of the Code of Professional Practice for teachers registered with the Royal Academy of Dance and I may be subject to sanctions.
If you are submitting this form via email please tick here and type your name below as a substitute for your signature.
Signature: / Date:
Send to
· Email: Please mark the subject of your email “CPD Declaration Form” and include your membership number
· Post: Attention of Membership Assistant (CPD), The Membership Department, Royal Academy of Dance, 36 Battersea Square, London, SW11 3RA, UK
PLEASE NOTE – if you are applying for an exemption, please send to your National Office. See below for address.
· Fax: +44 (0)20 7924 3129
Registered teachers resident in Australia, Canada, New Zealand, South Africa and the USA should return this form to their national office.
Internal Use Only
Staff Initials: / Date:
Declaration and Exemption Instructions and Guidance

The 2017/18 CPD year runs from 1 July 2017 to 30 June 2018. You are required to submit your 2017/18 declaration and/or exemption form by 30 June 2016. You can do this online (www.rad.org.uk/cpd) or by completing the form overleaf and sending it via email, post or fax to the relevant office.

Completing Section 1

Option A

If you have met your CPD 2017/18 requirement, tick Option A. By ticking this option you are confirming that you have completed the full requirement of 20 hours of CPD made up of:

· A minimum of 10 hours of workshops or courses that are delivered either in person or online (we call this Time-Valued CPD)

· A maximum of 10 hours of Independent CPD, this can include up to 5 different activities in 2 hour blocks like reading the Dance Gazette, choreographing or watching performances, observing classes and more

If you select this option, you are not required to submit any evidence with this form, but you must keep evidence of your CPD activity for two years and submit it to the Membership department when requested.

Option B

If you have not met your CPD requirement, tick Option D. Completing CPD is a requirement of your teaching registration and by ticking this option you may be subject to sanctions.

Option C

If you have not met your CPD requirement and believe that your circumstances from 1 July 2017 – 31 June 2018 mean that you should be eligible for a full (20 hour) exemption, tick Option B and outline the reason(s) why.

Option D

If you have met 10 hours or more of your CPD requirement (this can be either Time-Valued or Independent CPD or a mix of the two) and believe that your circumstances from 1 July 2017 – 30 June 2018 mean that you should be eligible for a part (10hour) exemption, tick Option C and outline the reason(s) why.

Completing Section 2 (you only need to complete section 2 if you selected Option C or D above)

Provide the reason why you are applying for an exemption. The RAD accepts the following reasons for exemptions:

· ill-health

· onerous caring duties for a close family member

· bereavement

· maternity and paternity leave

· unemployment

· career breaks

This is not an exhaustive list; you may apply for an exemption based on another reason/s that you believe affects your ability to meet the minimum CPD requirement.

In countries where there are ten or less teaching members, you may be eligible for a part-exemption (10 hours) if you are finding it difficult to participate in activities.

You are required to provide evidence to support your application e.g. a doctor’s letter or a letter from the social security office. The evidence should be dated, where possible. Exemption application forms will not be processed without documentation to support your application.

Completing Section 3

You must sign and date the form to confirm the CPD information you have given in this form is true to the best of your knowledge. Failure to do so or submission of a false declaration is a breach of the Code of Professional Practice for teachers registered with the Royal Academy of Dance.

Need help completing this form? Please contact the RAD Membership Team via

Phone: +44 (0)20 7326 8060

Email:

Registered teachers resident in Australia, Canada, New Zealand, South Africa and the USA should contact their National Office,

National Offices

Version 4 Royal Academy of Dance® is a Charity Registered in England & Wales No. 312826Updated 21 September 2017

BENELUX & FRANCE
Neeltje Holland Van Laarhoven

Beethovenlaan 54

6865 EB

Doorwerth

The Netherlands

(31) 6 2074 8924

www.radbenelux.eu

BRAZIL, PERU, ECUADOR & CHILE
Maria do Carmo de Kenny
Royal Academy of Dance Brasil Ltda.

Av. Angelica, 566/86

Santa Cecília

01228 000 São Paulo-SP

Brazil

(55) 11 3826 2498

www.royalacademyofdance.com.br

CARIBBEAN

(Jamaica, Dominican Republic, Bahamas, Trinidad & Tobago, Barbados, St Lucia, Antigua and Guadeloupe)
Diane C Bernard
Royal Academy of Dance
PO Box 1433
8 Rockhampton Drive
Kingston 8
Jamaica
(001) 876 755 0612

CHINA
Professor Ting Tina Chen
2nd Floor Tower 2
Dong Hai Commercial Building
588 Yan An Dong Lu
Shanghai China
(86) 21 6597 6399
e.

www.rad.cn.com

CYPRUS
Mr George Shantos
71Irinis Street
3041 Limassol
Cyprus
(357) 99 477 887

GERMANY, AUSTRIA and SWITZERLAND
Horst Vollmer
Royal Academy of Dance gGmbH
Waldenserstr 2-4
10551 Berlin
Germany
+49 (0)30 39 40 466 60

www.royalacademyofdance.de

GREECE
Veta Anastasopoulou
The British Council
17 Kolonaki Square
Athens 10673
Greece
(30) 210 364 3691

HONG KONG
Hong Kong Examinations & Assessment Authority
International and Professional Examinations Division
17 Tseuk Luk Street
San Po King, Kowloon
Hong Kong
(852) 3628 8755

INDONESIA
Lala Salendu
Yayasan Royal Academy of Dance Indonesia
Jl.Angur III no: 1 Cipete
Jakarta Selatan 12410
Indonesia
(62) 21 75 90 93 63

ISRAEL
Gali Zamir
Royal Academy of Dance
Hadar Str. 491
Neve Yamin
Israel.
(972) 52 3343 838

ITALY
Manuela de Luca
Royal Academy of Dance Srl
Via Vannetti 12
38122 Trento
Italy
(39) 0461 985 055

www.raditaly.it

JAPAN
Noriko Kobayashi
Royal Academy of Dance Japan
TRAD MEJIRO B2F, 2-39-1
Mejiro,Toshima-ku

Tokyo 171-0031
Japan
(81) 3 3987 3750

MALAYSIA
Nagaswari Murugiah

RAD Dancing (Malaysia) Sdn Bhd
No. 16F, 1 Sentral, Jalan Stesen, Sentral

50470 Kuala Lumpur

Malaysia
+6 03 2276 0052

MALTA
Sandra Mifsud
c/o29/10 Sir Luigi Camilleri Street

Sliema

Malta

SLM1848
(356) 7993 8584

www.radrmalta.org

MEXICO, EL SALVADOR, HONDURAS, COSTA RICA, GUATEMALA, PANAMA
Julieta Navarro
Royal Academy of Dance de Mexico AC
Amates 18, Fracc alconfores
San Mateo, Naucalpan CP
53240, Mexico
(52) 55 5360 2700

NORWAY, SWEDEN & DENMARK
Karina Lund
Smedstuveien 25

7040 Trondheim

Norway

(47) 979 592 0812

www.royalacademyofdance.no

PHILIPPINES
Lendl Agassi Concha

Examination Services Officer – Academic and Professional Exams
The British Council
10/F Taipan Place
F. Ortigas Jr. Road

1605 Ortigas Centre
Pasig City
Philippines
+63 (2) 555 3000 ext 141

National Offices

PORTUGAL
Margarida Sa Fialho
Royal Academy of Dance
Rua 4 Infantaria 86
1350-241 Lisboa
Portugal
(351) 21 383 1849

http://royalacademyofdance.pt/pt

SINGAPORE
Mona Lim
Royal Academy of Dance Singapore
Pte Ltd, Farrer Road Post Office
PO Box 106
Singapore 912804
(65) 6762 8993

www.rad.sg

SOUTH KOREA
Hyun Joo Ham
# 1703 Artnouveau Palace
258 Sukchonhosu-ro
Songpa Gu
Seoul 05624
Korea
(82) 2 796 0003

www.radkorea.org

SPAIN, GIBRALTAR & ANDORRA
Maria José Antón
Royal Academy of Dance SL
Ventura i Gassol 3, 5è-3a
43203 Reus,Tarragona
Spain
(34) 977 34 24 89

www.rad.org.es

SOUTH ASIA
Ranmali Mirchandani

Royal Academy of Dance
40A, Lake Gardens

Off Lake Drive

Rajagiriya 10100

Sri Lanka
(94) 77 734 9399

TAIWAN
Shu-Yu Lin
5F, No 122, Sect 7
Chung Shan N. Road
Taipei 11151
Taiwan
(886) 22 871 5615

www.rad.org.tw

THAILAND
Glenn van der Hoff
RAD Dancing (Thailand) Co.Ltd

121/12, Moo 10, Changmai-Hangdong Road

Tambon: Pae Dad

Ampur: Muang

Chiang Mai 50100

Thailand

(66) 0 5327 4841

www.radthailand.org

TURKEY

Seda Baykal

British Council Examinations Department

Educational and Professional Exams

Buyukdere Caddesi Maya Akar Centre

No: 100 - 102 Kat: 5

Postcode: 34394

Esentepe – Istanbul

Turkey
0090 212 355 5623

UNITED ARAB EMIRATES, BAHRAIN, QATAR & OMAN
Shabnam Habib

The British Council

PO Box 1636

Dubai
U.A.E.
971 4 3135 568

UNITED KINGDOM

The Membership Department (CPD)
Royal Academy of Dance
36 Battersea Square
London
SW11 3RA
UK
44 (0) 20 7326 8060

www.rad.org.uk

Version 4 Royal Academy of Dance® is a Charity Registered in England & Wales No. 312826Updated 21 September 2017