Organization Registration

NOTICE:

The request form below, to establish a PDA LMS organization account, should be completed and submitted by the organization's owner, president, CEO, Director, etc.
Only one (1) account should be established per organization.

**TO ESTABLISH A NEW PDA LMS ORGANIZATION ACCOUNT ACCOUNT, PLEASE COMPLETE THE FORM BELOW:**

(Once completed, click the 'Submit' button located in the bottom left corner of the form)

Organization Request to be Submitted by Appropriate Personnel:*
In order to submit a request to have an LMS account established for your Organization, you will need to have the authority to do so. Are you an owner, president, or CEO of the organization, or do you hold a senior management position within the organization? (If 'NO', please have the appropriate personnel complete and submit this request form)
- I am an Owner/President/CEO of the Organization.
- I hold a senior management position within the Organization.
Name of Organization:*
(Legal entity name)
Date Entity Established:*
MM slash DD slash YYYY
Name of Person Completing Form:*
Please include first and last name.
Email Address of Person Completing Form:*
Job Title of Person Completing Form:*
Will you be the designated 'LMS Administrator' for your organization?*
An 'LMS Administrator' a/k/a 'LMS Org Admin’ is the person at your agency who is granted access to your agency's LMS organizational hierarchy for the purpose of setting up training accounts when staff members or volunteers are on-boarded. If you opt to fill the role of 'LMS Org Admin', select 'Yes' below; however, if you would like to delegate this role/responsibility to another staff member, please select 'No' below and provide that staff member's contact information in the subsequent fields.
- Yes
- No
Name of LMS 'ADMIN' Designee:*
First Name Last Name
Email Address of LMS 'ADMIN' Designee:*
Job Title of LMS 'ADMIN' Designee*
Organization Phone Number:*
Physical Address of Organization:*
If the organization serves multiple locations, please enter the address where the home/administrative office is located.

Street Address Address Line 2 City State ZIP Code
Billing Address:
- Same as physical address
Billing Address:
Street Address Address Line 2 City State ZIP Code
Organization Website/URL
If your organization has a website, please enter the URL into the field below.
Organization Type:*
From the drop-down list, please select your organization's type.
Other Organization Type:
Organization County:*
If the organization serves multiple counties, choose the county where the main/home/administrative office is physically located:
Area Agency on Aging (AAA) Affiliation?*
If your organization is either 'funded by' or 'contracted with' and Area Agency on Aging (AAA), please select the name of the AAA from the drop-down list below. If this does not apply to your organization, select '*No AAA Association'.
Is your agency licensed as an Adult Day Center (ADC) or Older Adult Daily Living Center (OADLC) with the Pennsylvania Department of Aging (PDA)?*
- NO
- YES
Older Adult Daily Living Center (OADLC)
If your agency is classified as an Adult Day Center (ADC), and is currently a licensed/approved ADC with the state of Pennsylvania, feel free to submit this form to request a new PDA LMS organizational account.
If your agency is NOT yet approved as a Pennsylvania licensed ADC, or if in process of submitting an application for ADC licensure, DO NOT submit this online registration form at this time. Read on...
The Pennsylvania Department of Aging (PDA) Division of Licensing requires submission of an Adult Day Center (ADC) application packet prior to receiving approval to access the PDA LMS training portal to complete the online Older Adult Daily Living Center (OADLC) Director Training. Please contact PDA to request an ADC application for license. Visit https://www.aging.pa.gov/organization/licensing-and-monitoring/Pages/Adult-Day-Center-Licensing.aspx#.VL_oSi7F-T4 for details and access to the application procedures.
As part of the application packet, there is a form to request access to the online Older Adult Daily Living Center (OADLC) Director Training. Once PDA receives your completed application packet, a representative will forward the form directly to the PDA LMS Help Center to establish an account for your ADC, after which you will receive an email that contains login credentials to access your new PDA LMS training account.
Email
This field is for validation purposes and should be left unchanged.

Organization Registration

NOTICE:

TO ESTABLISH A NEW PDA LMS ORGANIZATION ACCOUNT ACCOUNT, PLEASE COMPLETE THE FORM BELOW:

(Once completed, click the 'Submit' button located in the bottom left corner of the form)

Older Adult Daily Living Center (OADLC)

**TO ESTABLISH A NEW PDA LMS ORGANIZATION ACCOUNT ACCOUNT, PLEASE COMPLETE THE FORM BELOW:**