Application - Clinic Director - CAIP - Canadian Association of Irlen Professionals

CANADIAN ASSOCIATION OF IRLEN PROFESSIONALS
REQUEST FOR CLINIC DIRECTOR MEMBERSHIP

* Indicates required field

Name *

First

Last

Address *

Address 2 *

City *

Province *

Postal Code *

Date *

Phone Number (Primary) *

Phone Number (Cell) *

Phone Number (Office) *

Email *

Clinic Director (full membership only)

When were you certified by the Institute? mm/dd/yy *

In what areas or locations do you practice? *

Indicate the average number of hours per month you spend on your Irlen practice. *

Are you currently authorized by the Institute to train screeners? *

Yes No

How many screeners have you trained? *

How many screeners have you trained that are still active? *

By submitting this form, you agree that if admitted to CAIP, will you fully and completely abide by its Code of Ethics. Clinic Director membership fee: $100 per year.

Agree & Submit

CANADIAN ASSOCIATION OF IRLEN PROFESSIONALSREQUEST FOR CLINIC DIRECTOR MEMBERSHIP

Clinic Director (full membership only)

CANADIAN ASSOCIATION OF IRLEN PROFESSIONALS
REQUEST FOR CLINIC DIRECTOR MEMBERSHIP