Application If you are interested in completing your placement with us, please complete the registration form below. Name: * First Name Last Name Preferred name (if different): Email address: * Phone number: (###) ### #### Address: Address 1 Address 2 City State/Province Zip/Postal Code Country School or university name: * Name of course/ Program: * Year of study: * Expected graduation date: * Total placement hours required by your course: * Hours completed so far: When are you available to begin your placement? * Preferred days/times for client sessions (we can offer sessions Mondays to Saturdays - mornings, afternoons and evenings): * How many hours per week can you commit to your placement? * Do you require supervision? * Do you have professional liability insurance? * Yes No In progress Do you have a current enhanced DBS check? * Yes No In progress Are you legally eligible to work or volunteer in England? * Yes No Are you registered with a professional body? * Yes No In Progress If so, what is your professional body and registration number? * Name of one academic or professional referee: * Referee relationship to you: * Referee email address: * By submitting this application, I confirm that the information provided is accurate to the best of my knowledge. I agree I disagree Signature: Thank you for sending your registration form, we will be in touch shortly.
