Formulaire d adhésion / Registration form

Transcription

1 Formulaire d adhésion RITMA / RITMA Registration form $ taxes ($26.21) = For membership to one RITMA association $ taxes ($44.93) = For membership to 2 or 3 RITMA associations Kinésithérapeute / Kinesitherapist Massothérapeute / Massage Therapist Naturopathe / Naturopath Orthothérapeute / Orthotherapist Ostéopathe / Osteopath N.A.S / S.I.N: Nom / Name: Prénom / First name: Courriel / Adresse / Address: Date de naissance / Birth date: Code postal / Postal code: Référence/Reference : Tél. Rés. / Phone Home: Tél. Trav. / Phone Work: Cell: Télécopieur / Fax: Discipline(s) pratiquée(s) / Speciality(ies) Diplôme ou attestation de cours? Diploma or proof of education? Oui / Yes Non / No Pratiquée depuis quelle année? In practice for how long? Date : Signature : Complétez ce formulaire d adhésion et faites le parvenir au RITMA, avec une photocopie de vos diplômes/attestations de cours, ainsi qu un chèque fait à l ordre du RITMA au montant de $. Si vous n êtes pas accepté comme membre, votre chèque vous sera retourné sans être encaissé. Please fill out this form and forward it to RITMA with a photocopy of your diploma(s) and/or proof of education and a cheque in the amount of $ made out to RITMA. Your cheque will be returned in the event that your membership is denied. Page 1 de 4

2 COMMANDE DE LIVRETS DE REÇUS ORDER FOR RECEIPTS BOOKS (Commande minimum / Minimum order = 2) S il vous plait, me faire parvenir des livrets de reçus TRADITIONNELS pour assurances: Please send me TRADITIONAL receipts books for insurances : Association des Kinésithérapeutes RITMA Association des Massothérapeutes RITMA Association des Naturopathes RITMA Association des Orthothérapeutes RITMA Association des Ostéopathes RITMA RITMA Kinesitherapists Association RITMA Massage Therapists Association RITMA Naturopaths Association RITMA Orthotherapists Association RITMA Osteopaths Association TRADITIONAL receipt book (100 pages) 3 visits per page (WITHOUT duplicate) 6.10$ + taxes (0.92$) = 7.02$ Livrets de 100 reçus / Pads of $ = Total: $ S il vous plait, me faire parvenir des livrets de reçus PROFESSIONNELS pour assurances: Please send me PROFESSIONAL receipts books for insurances : Association des Massothérapeutes RITMA Association des Naturopathes RITMA Association des Ostéopathes RITMA RITMA Massage Therapists Association RITMA Naturopaths Association RITMA Osteopaths Association PROFESSIONAL receipt book (50 pages) 90 visits per page (with duplicate) 8.25$ + taxes (1.24$) = $9.48$ Livrets de 50 reçus / Pads of $ = Total: $ Ci inclus, mon chèque ou mandat poste au montant de $. Here included my check or money order to the amount of $. Signature: Membre/member#: Date: Page 2 de 4

3 ACCEPTATION OF CODE OF DEONTOLOGY AND RITMA S RULES It is understood that RITMA reserves the right to made amendments to this document and I agree to respect said amendments as soon as I am made aware of them. I accept the contents of this document and agree to respect all of the aforementioned rules under penalty of sanction. Date Signature of member : Signature of RITMA S representative : Page 3 de 4

4 PROVOSIONS RELATING TO THE PROTECTION OF PRIVACY ACT OF PERSONAL INFORMATION IN THE PRIVATE SECTOR (ACT68) You have relinquished your personal information for our records. As established by act 68, you consent to our keeping on file any and all information you have given us, whether written or oral, unless otherwise specifically stipulated on your part. It is also understood that your consent is valid for a 5 (five) year period unless otherwise specifically stipulated by you in the way of a registered letter. CONSENT I consent freely and overtly that RITMA (Regroupement des Intervenants et Thérapeutes en Médecine Alternative) retain on file all/any information I have given and will give, whether orally or in writing, as of this moment. Date : Signature : Page 4 de 4

5 Full name: Solemn Declaration Have you ever been named in a criminal or civil lawsuit? No Date: Has a professional complaint or lawsuit ever been filed against you? No Date: Have you ever been formally charged with a criminal offence? No Date: Have you ever been suspended or had your membership revoked by a professional association or organization? No Date: I solemnly swear that I have answered these questions truthfully and hereby agree to disclose to RITMA any changes affecting the accuracy of my answers within 10 days of said change. I understand that failure to do so will result in my immediate temporary suspension from this association. Signature: Print name: Signed at: on this date